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DUNKIN DONUTS-BASKIN ROBINS - ESTABLISHMENTS ��nw�Q D oo(��f��ariva re6i og 2�'2 Derb f Sot ftNIVERSAL® UNV-12110 MADE IN USA FORSUSESTRYTAINABLE MiN.Wa= IrnTlnnvE caNTENrioz C.b.d Rber S..6-9 POSTZCNMM v ,sfiyrogremorg 7i ur.R� Commonwealth of Massachusetts City of Salem Board of Health Kimberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/06/2011 ESTABLISHMENT NAME: Dunkin Donuts/Sean's Donuts Inc. File Number:BHF-2004-000163 282 Derby Street Salem MA 01970 LOCATED AT: 0105 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2011-0279 Jan 1,2011 Dec 31,2011 $140.00 / WATER SOURCE: CITY ESTABLISHMENT WATER SEWER DISP: CITY WATER Total Fees: $140.00 PERMIT EXPIRES IDecember3l, 2011 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, beofre any revonations,improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4n'FLOOR TEL.(978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR FX;RJ-X,NaAUMSALL f.CONI DAVID GREENBAUM,RS ACTING HEALTH AGENT 2011 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT_ % TEL# �n1, Lf7 �' C3 ADDRESS OF ESTABLISHMENT � �,.- FAX# L.4 1`V1 MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAMMp,!�-5(A- Ita TEL# ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) n_c 0, CERTIFICATE#(S) (Required in an establishment where potentlall hh ardyous food iss prepared) EMERGENCY RESPONSE PERSON G.7t9 CJ ��I U y L �Y� hOAIe TEL# �77`l� VN [HOU OTuesd Wednesd ":'.Thula Fri $atu Sunday RS OF OPERATION Please write to lYne of day. orexangelian-11 — TYPE OF ESTABLISHMENT FEE fcheck only) RETAIL STORE YES NO less than 1000sq.fL =$70 1000-10,000stik =$280 more than 10,000sq.ft. =$420 _---- less than ------------------------- RESTAURANT NO 25 seats $140 (Outdoor Stationary Food Cart$ YES 25-99 seats more than 99 seats -$42U -----•-•----*'Y-§----_N_-O....... --_-.--------•-••-----•--•-•-'•-------------------*..--.--------------•$••--10 ....BED/BREAKFAST! YES QHILDCARESERVICES/NURSINr HOME............................................................................................................................... ADDITIONAL PERMITS MAKE(not just serve)ICE CREAM,YOGURT/SOFT SERVE YES NO $25 TOBACCO VENDOR YES NO $135 ALL NO*PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all pians for such must a submittetSion7419A, oved by the Salm Board of Health. P cant o h er I cert(fy under pat s and penalties of perjury that 1,to my best knowledge and belief,have filed all state tan si ar the 1 SignatureDate l� Social Security or Federal Identification Number Revised 10/7/I1 FOODAP201 I,adm Check#&Date $ T Y CITY OF SALEM BOARD OF HEALTH Establishment Name: 7VtJK )T4 Dc, eQj\S Date: y-1 11 Page: 1 of Nem Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- 140. Reference R—Red Item Verified PLEASE PRINT CLEARLY l — C=_S i�3Lis1\ t•,�t� iv - , S TI ,ast „i -, CL;. `���a`1 -��, � U Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion / ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Fpod Code. I nr derstand that noncompliance may result in daily fines of twen -five dollars/ [suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. I '` / / p I ❑ Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures - Violations Related to Foodborne Illness interventions and Risk According to Law Cooled to Factors(/tean 1-22) (Cont.) 41°F/45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 302.12 Additives* 3-50LI6(B) Cold PHFs Maintained at or below 3-3 302.14 Protection fromUnapproved Additives* 590.004(17) 4101450 F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140°F. * 7-101.11 Identifying Information-Original 3501.16(A) Roasts Held at or above 130'F. Containers* 7-102.11, Common Name-Working Containers* 20 Time as a Public Health Control 3-501.19 Time as a Public Health Control* 7-201.11 Separation-St�rage- 7-202.11 .Restriction-Presenceand Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 SanChemirs.cals Criteria i Chemicals* 21 3-80.1.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* 7-204.14 Drying Agents.Criteria* Beverages with Wooing,Labels* 7-205.11 Incidental Food Contact,lubricants* 3-801.11(B) Use of Pasteurized E*°s* 3-801.11(D) Raw or PartiallyCooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.22 Rodent Bait Stations* 3-801.1I(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.110(i)(2) Eggs- 155°17 15 See. Patio IIS.*eM o e i r br Eggs-Immediate Service,1450F15sees 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 sec. 3401.11(B)(1)(2) Pork and Beef Roast- 1.30'F 121 min* SPECIAL REQUIREMENTS 3.401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec.* catering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec.* above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be.debited under#29- Microwave 165°F* Special Requirements. 3401:11(A)(I)(6) All Other PHFs- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-003.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3.403.11(B) Microwave- 165'F 2 Minute Standing Critical..and non-critical violations, which do not relate to the Time* foodborne illness interventions and risk factors listed'above, can be 3.403.11(C) Commercially Processed RTE Food- found in the following sections of the Food Code and 105 CMR 1400F* 590.600. 3-403.11(E) Remaining Unsliced Portions of Beef Hem F Good Retail Practices FC 590.000 Roasts': 23. Man ement and Personnel _ t FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FI C-3 .004 25. _Equipment and Utensils ,, FC-4 .005 3-50L14(A) Cooling Cooked PHFs from 140'Fto 26. Water.Plumbing and Waste ' FC-5 .006 70°F Within Z Hours and From 70°F 27. Physical FacilityFC-6 Z07 to 41°F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials ! FC-7 .008 i 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements ,009 Temperature Ingredients to 41°F/45°F 30 I Other Within 4 Hours* s:swxt<aex. °Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. t , Massachusetts Department of PublicHealthSalem Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date Type of Operation(s) Tvoe of Inspection zyyy ann r_ (� Food Service outine Address Risk Retail $Re-inspection Level Residential Kitchen Previous Inspection TelephoneILI ❑ Mobile Date: Owner �� HACCP YM ❑❑ Cate erTemorary ElPre-operation 12y) ke< ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint In:Inspector Out Permit No. ❑Other Each violation checked requires an Van tion on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco 1 . Violations marked may pose an imminent health hazard and require immediate corrective 590�� 590.009( action as determined by the Board of Health. _FOOD PROTECTION MANAGEMENT`. ❑ 12. Prevention of Contamination from Hands [1 1. PIC Assigned/Knowledgeable/Duties ____ E] 13. Handwash Facilities [EMPLOYEE HEALTH ,,. PROTECTION FROM CHEMICALS ❑ 2 Reporting of Diseases by Food Employee and PIC " ❑ 3. Personnel with Infections Restricted/Excluded El 14.Approved Food or Color Additives ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE__ '-. * '*- ❑ 4. Food and Water from Approved Source TIMEITEMPERATURE CONTROLS(Potentially Hazardous Fooda_j ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [:117. Reheating `❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION , ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing .REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS.(HSP)I El 10. Proper Adequate Handwashing El21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices .CONSUMER ADVISORY �. A''== [:122. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below c x 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-a)(sso.00s) cited in this report may result in suspension or revocation of the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you (j 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:s901napxtFom,Bia.Erc Inspector's Signature: Print: 1 _ PIC's Signature: Print: I Page o12 Pages � y Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION 8 Crass-contamination FOOD PROTECTION MANAGEMENT 3-302.1](A)(1) Raw Animal Foods Separated from I 590.003(A) Assignment of Responsibility* Cooked and RTE Foods* 590.003(6) Demonstration of Knowied e* Contamination from Raw Ingredients 2-103.11 Person in charge-dupes 3-302.1.1(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) I Food Protection* require reporting by food employees and 3-342.15 Washing Fruits and Vegetables applicants* 3-304.11 Food Contain with Equipment and 590.003(.F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In - Contamination from the Consumer Charge* 3-306.14(A)B) Returned Food and Reservice of flood* 590,003(G) Reng by Person in Char e" 3 590.003(D) Exclusions and Restrictions* Disdiort of Adulterated or Contaminated, 590.003(E) Removal of Exclusions and Restrictions 3-701.11 Discarding or Reconditioning Unsafe Food* FOOD FROM APPROVED SOURCE _ 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) _Compliance with Food Law* 4-501.1 I 1 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water . 3-202.13 Shell Eggs* Temperatures* 3-202.1.4 Eggs and Milk Products,Pasteurized* 4-501.11.4 Chemical Sanitization-temp.,pH; 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness.* 5-101.11 Drinking Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.1.1. Cleanine Frequency of Equipment - * 9 Y F�1 1men[Fcod 590.(H16(.B) Water MeeCs Standards in 310 CMR 22.0 - Shellfish COntact Surfaces and Utensils*sh and Fish From an Approved Sourca 4-702.1 1. Frequency of Sanitization of Utensils and - 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish" 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Re MatoAuihorrt Game and Wild Mushrooms Approved by 2-301.11 -Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.1.2 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* it Good Hygienic Practices g Receiving/Condition 2-401.1] Eating,Drinking or Using Tobacco* 3-202.1 t PHFs Received at Proper Tem rattures* 2-401,12 Discharges From the Eyes,Nose and 3-202.1.5 Package integrity* Mouth* 3-101,.11. Foci Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contaminatioafrom 3-203.12 Shellstock Identification Maintained'* Employees* Tags/Records:-Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11. Numbers and Capacities* 3-402.12 Records,Creation and Retention" 5-203.11 Location and Placement* 590.004(7) Labeling o9 Ingredients' q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11. Specialized processing Methods* Devices 3-502.12 Reduced oxygen packaging.criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301..1.2 Hand Drying Provision ° Denotes critical item in the Weral 1999 Fond Caie or I0i CMR 590.000. \ -�-� BOARD OF HEALTH - Establishment Name:�.0 IJA_W0/"n, \ )UY1,,,I.L;2 `J Date: Pager Of _ Item- Code C-Critical Item - DESCRIPTION OF VIOLATION ! PLAN OF CORRECTION Date No. Re ence R–Red Item ? a PLEaSe PRINT ct.EaRLr Verified r� S O n A Q d v z n. O C JC-- S' C //. S(/4' )01 ' _PA D 40 is D O - r � Wk M x,/424 Ell /,.P Ad 10A14,1'1n,r.,,, 11n QLL . �. (w_ ' t/ ` Ik — /� ' � c _L? /Xi I _ rn;o/4�_ , �U �I,_ s < n^ ,P N 11n l, JC. — �. i " ��,� n n Anne i_/n-� it OA D U e A DU4d I dkA 1 Discussion With Person in Charge: Corrective Action Required: L)No . LlYes -41114 64 m w- ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension ❑ Embargo ❑ Emergency Closure i ❑ Voluntary Disposal ❑ Other FORM 7348 (REV. 7/2000) HOBBS & WARREN, - BOSTON This Form Approved by the Department of Public Health Violations Related to Foodborne Illness Interventions and Risk 3-501.14(C) PHFs Received at Temperatures Factors(Red Items 1-22) (Cont) According to Law Cooled to 41*F/45'F Within 4 Hours.* PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs .14-: Food or Color Additives 19' PHF Hot and Cold Holding 3-202.12 Additives* 3-501.16(6) Cold PHFs Maintained at or below 3-202.14 Protection from Unapproved Additives* 590.004(F) 41°F/45°F* 15. Poisonous or Toxic Substances 3-501.16(A) Hot PHFs Maintained at or above 7-101.11 Identifying Information-Original 140°E* Containers* 3-501.16(A) Roasts Held at or above 130°E* 7-102.11 Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-203.11 Toxic Containers-Prohibitions* POPULATIONS(HSP) 7-204.11 Sanitizers,Criteria-Chemicals* 1 '21 ' 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Criteria* °'` Beverages with Warning Labels* 7-204.14 Drying Agents,Criteria* 3-801.11(B) Use of Pasteurized Eggs* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re-served.* 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY 22'. 3-603.11 Consumer Advisory Posted for Consumption of TIME/TEMPERATURE CONTROLS Animal Foods that are Raw,Undercooked or 16 - Proper Cooking Temperatures for �Wv not Otherwise Processed to Eliminate PHFs "``"' Pathogens.* E*01r 11112001 3-401.11A(1)(2) Eggs- 155*F 15 Sec. 3-302.13 1 Pasteurized Eggs Substitute for Raw Shell Eggs* Eggs-Immediate Service 145'F 15 Sec.* 3-401.11(A)(2) Comminuted Fish,Meats&Game SPECIAL REQUIREMENTS Animals- 155°F Sec.* 590.009(A)-(D) Violations of Section 590.009(A)-(D)in 3-401.11(B)(1)(2) Pork and Beef Roast-130'F 121 Min.* catering,mobile food,temporary and 3-401.11(A)(2) Ratites,Injected Meats-155'F 15 Sec.* residential kitchen operations should be 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, debited under the appropriate sections Stuffing Containing Fish,Meat, above if related to foodbome illness Poultry or Ratites- 165*F 15 Sec.* interventions and risk factors. Other 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks 590.009 violations relating to good retail 1450F* practices should be debited under#29- 3-401.12 Raw Animal Foods Cooked in a Special Requirements. Microwave 165°F* 3-401.11(A)(1)(b) All Other PHFs- 145'F 15 Sec.* VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 17 Reheating for Hot Holding (Blue Items 23-30) 3-403.11(A)&(D) PHFs 165*F 15 Sec.* Critical and non-critical violations, which do not relate to the 3-403.11(B) Microwave- 165'F 2 Minute Standing foodborne illness interventions and risk factors listed above, can be Time* found in the following sections of the Food Code and 105 CMR 3-403.11(C) Commercially Processed RTE Food- 590.00. 140°F* Item Good Retail Practices FC 590.00 3-403.11(E) Remaining Unsliced Portions of Beef 23. Management and Personnel FC-2 .003 Roasts* 24. Food and Food Protection FC-3 .004 18 Proper Cooling of PHFs 25. Equipment and Utensils FC-4 .005 3-501.14(A) Cooling Cooked PHFs from 140*F to 26. Water, Plumbing and Waste FC-5 .006 70'F Within 2 Hours and from 70*F 27. Physical Facility FC-6 .007 to 41°F/45'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41'F/45'F 30. Other Within 4 Hours* *Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. ? .5•,�1 �1,..w:f. >" i`:��XC`� Vi4��, .,pt2 =LTf�hH. .."4 �r a� J�brrrdi" ���-r''11W1I Masscichusetts Department of Public Health Salem Board of Health 120 Washington Street,4t" Floor Division of Food and Drugs t Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT 1 Tel (978) 741-1800 Fax (978) 745-0343 Name T e of 0 erasion s Tvoe of Inspection -Food Service ❑ Routine Address ' e I ! Vsk ❑ Retail fie-inspection I� Level ❑ Residential Kitchen Previous inspection Telephone / El Mobile Date: �Yaq /0C [:1 Temporary ❑ Pre-operation Owner ,r L Q HACCP Y/N ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) TimeIn: / ❑ Bed&Breakfast El General Complaint E] HACCP Inspector J ^P \ 0utfl Z.J Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. N. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT Ft,® ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYE£HEALTH� "`""`"""` .®.. '.Di-se �.......,,m„�m.��„�.„ F"PROTECTIQNFRON2CHEMrOdL$a ❑ 2.•Reporting of Diseases by Food Employee and PIC - '.�'� El14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals "FOOD FROM APPROVED SOURCEU_�I5i,;'!„„") `_ El 4. Food and Water from Approved Source F TIME(TEMPERATUR�CONTROLS•(Potemially Hazardous Faiids) c"�� . ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION` a ,) k" , y ai El 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing LEREQUIRPN(ENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP);; El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing E] 11. Good Hygienic Practices ®'CONSUMER ADVIsQRY; 6 3 {�, i t E ❑22. Posting of Consumer Advisories Violations Related.to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR ofH Iy Health. i 5 _ 590.000/federal Food Code. This report, when signed below C 1' Nby a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) 1 - establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S.501na IFom 14,D I \ Inspector's Signature: \ Print: V PIC's Signature: Print: e Page / oi_-Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination I-590 003(A) Assignment of Responsibility* 3-302.11(A)(7) Raw Animal Foods Separated from 590.003(BTDemonstration of 7Snowledge* Cooked and RTE Foods* 2-103.1 I Person in charge -dupes _ _ Contamination from Raw Ingredients 3-302.11(.4)(2) Kaw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3302.11(A) Food Protection* applicants* 3-302.15 washing Fruits and Vegetables 59Q003(1`) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting bj Petson in Chazge* 3-306.14(A)(B) Returned Food and Reservice of Fund- 31 591).003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) 1 Removal of Exclusions and Res r et ons Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* q Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com rtiance with Food Law* 4-501.111. Manual Warewashing-Hot Water 3-201.12 Ford in a Hermetically Scaled Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Plot Water 3-202.1.3 Shell Eggs* Sanitization Temperatures* 3-202.14 Fg Ls and Milk Products,Pasteurized* 4-501.11.4 Chertucal Sanitization-temp.,pH, 3-202.16 lee Made From Potable Drinking Water* concentration and hardness, 'r 5-L0111 Donkin Water from an Approved System* 4-601.11(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 22.0* Sheffish and Fish From an Approved Source Contact Surfaces and Utensils*4-702 11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment, Shellfish" 4-703.11 Methods of Sanitization-Her water and 3-201.15 Molluscan Shellfish from NSSP Lasted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Author 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices g Receiving/Condition 2-401.11 Eatin ,Drinking or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin Contamination When Tustin 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-2031.2 Shellstock Identification Maintained* Employees* Handwash Facilities Tags/Records:Fish Products 13 Conveniently Located and Accessible 3-402.11 Parasite Destruction* 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.11 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging.criteria* 6-301.11. Handwashing Cleanser,Availabilit 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand Dr in Provision '°Denotes critical Item in the federal 1999 Food Cate or 105 CMR 590.000. - CITY OF SALEM BOARD OF HEALTH Establishment Name: Do, I \ ,� Date: 9 / Page: of Y Item Code C—Critical Item - Date DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION No. Reference R—Red Item verified PLEASE PRINT CLEARLY //•• v • VIv 1 LW 1 /h y t _ y i S Discussion With Person in Charge: Corrective Action Required: ❑ No - Yes t I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance El Employee Restriction/ inspection, to observe all conditions as described, and to Exclusion violations before the next ins p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that \ noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal 0 Other: ?-5t11.14((,) PHFs Reuived at"Pemperxtures Violations Related to Foodborne Illness Interventions and Risk According to Lau•Cooled to Factors(fletns 1-22) (Cont) 41°F/45'F Within 4 Hours, x _ PROTECTION FROM CHEMICALS _I-501.15 Coolim�Methods for PHFs 14 food or Color Additives 19 T PHF Hot and Cold Holding -- 3-501.16(B) Cold PHFs Maintained at or below 3-2112,12 Add fives �90.0(,4(F) 41145`is. 3-362.14 ProtectionfiornUna> ros=edAdditivcs* 3-5t,;l.IbiAj F1ntP11Fs;vlaintautedaiorabove 1-S Poisonous or Toxic Substances 1kreliI litm r Information On iaa, 140-F, 01.11 r _ I F t 50I 6,Ai Rva,ts Held at or abo%e 13U Contw r�' 02.11 Ccabnum'Nas Work e" ( mtar -r3"� ?•- ' Time as a Public Heattb Control - -- iV l i �- as a Pubitc heal h t ontral" 1-20( 1] 55 t, t rn-5ir s ak _- .on-Y—r �,<-eco 202.I2 C01011poni,of Ute III REOUIREMENTS FOR HIGHLY SUSCEPTIBLE 2 ')4.t1 1 oxi t ,s t finer Prohil .t r , —� POPULATIONS(HSP)_ - `� t '(,tit Sannvu. hitt tt+ Chou.. l� --- '-"-`- �t St;1 i 3t^,)Tl;�t t tea sEed Pa tai ted kucecmtd� r - .12� China as tot,R tcht 1 nC t� < rc. n'=-� t F I Z; i-'b4 id Dyne `<serie.Cntc rt- t -� i3c3ets e. vithltasnm l_t Is- ---� 8ii31ttH) 114 rt la leurl cdt D5J 1 In;td nt t) I,ubr scan �,` _.� 3 ,01 10)) k;wzm 11u1,AI (,xk.td Animal Ft9A and �6.k Ra , rlc usis 1. rt Si d ss ,ut 'N 1 r 06.1) Rrx„ 13 ,!Y-;llamn� s ; s 1 ct&_SS,P`=rilur . !.z,itti.(.,L.3 . ittonito�nr` i CONSUMER ADVISORY TWEfPEMPERATURECONTROLS :. 2 1 3LO. 11 C ooamn,r is riso.k P Atcrj R,r f nt nt;�tit)tt(it Phot sirs, or i 16 i T Groper Cooking Tempe,atures fog . i PHFs 11 101311r11( j i ( sR r t e s nu:.d t 7c c� [ 5 1 s5aee t .`Gn t , 11,ltvan,, dt f,f SLOSwofs. f,)' shelf ii L, } b ' t t, Sr s „ t1 SPECIAL REOWREMENTS 1 ,f21 t c , 1s if R, i -' t t s rain' -. _ r- 1 VL§'H '1 V l' do -Jti_ii rl 3i-{1)j 38 —� (r`,Crl tv QA,ird'..1 ht 1, tcnsp orio, and 401.P sAf'+i Pu,•rr,,'_1v"+'i t t r. �_';�nit �,i til= , = cess..im,al kiiCh(:!l he � l St i�,=li 7 14,t t.j,hist, Rfeat, t..6o"'a kultler Sin. a UZCi9Cidtt `",110 YS 5 =ikS i �..4. .�, t?. i ---- ter Hot hot#,r,z + t'.z`tLA`1(;;15 REt_.47"EC t6 +'3L7tr F?EI"kt`i t"o4.kG71C;G`S i ! s +_ts tr� ,l hitt) wt„� s __1 tltent4��-3i)p - 4-10?.2 11131 4is <x,tve ie < Nl nc< Si m iiug C rr 1.d [Itzi x +t su_. a rr h do ,ttl tcif< r 'Gr l I tic _ _ PS ��h rqe-illi s .urea,.rrt, .,a S.trlr; j �7(,. r?;.rt.f.,t.r r. enR Lr t .__._.._._.__._..-.___— ...._.___..___,� T t--i r3.1 It C? i”,..iatd til' 14.nxi- ",fps'!.., 'reg ra.tg se we,, FrUCI i`odc, `t. C,1 a. _ h t` (i000, 00, teen_6-1- - 1-1 RaPa,t Pr�cte�cv FC ,f)._c-- t lap t E Q d V t lr t -� FG 2 r c+xi I,! a ci P Jre("-0 oo cC i t `: ! 1ti Proper Coaling of PHFS I - .. - ,._._._ 2' r ti, r ,+nG itE� 9 t t ? �F - _._ .._I t ' 5ol,I.4A) C,xdmlr CrxSS d Ptff=s R n i d T=to s 3,. ,. r a'er *t ib, �•t J t0 ' e£ Cos- TY } E Wi .i; 1 t ou +i 1 corn r 1 ' .� r 2 a t, s i=, ._ - b � t " 11 ,F W-ah t H r l -3 r s � ,s0, T�X;f]N .,t ,S s C r 2 JO S _� - 11th) C„ht PiIC 0.' A I -.at1m1 taC i If sn1-r trnre is u..alt,., 7 E!45`F !i tit r•t ;i,ns :�. � r �., �t. -* :nu, i,er In the J-gel i ..,R.-�;, .Ily+s.. +.r.. ..{,... 'k -.'f ,.T4s..:`,`�r+?a`E,+�lp•:.�e,�i�. .r . s{. > - .!. .y..•.a„ ..Jgf.ffi}i�t� .,(,�.x�Y.. 4^�.B_'. .E..#p,�yli..' Massachusetts Department of Public Health Salem Board of Health 120`Washington Street;"0 Floor Division of Food and Drugs 1 Salem, MA 01970.3523 FOOD ESTABLISHMENT INSPECTION REPORT 4 I Tel. (978) 741-1800 Fax (978) 745-0343 Name !'� �) D a Type of Ooerationfsl Tvoe of Inspection I / ✓� Ike I/Jdt ©'Food Service ❑ Routine Address �a Risk ❑ Retail ER-Re-inspection Level ❑ Residential Kitchen Previous Iction Telephone g _2 1- ❑ Mobile Date: Owner ^F HACCP YM El Temporary El Pre-operation , ❑ Caterer ❑Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint r In:'a•'JJ ❑ HACCP Inspector l L).Lo ( Out -d�_ Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT s.,,,a, El12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities , EMPLOYEEHEALTH :PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals FOOD FROM APPROVED SOURCE TIMEITEMPERATURE CtINTROL$ PotenClill Hazardous Fiiods h ❑ 4. Food and Water from Approved Source ( Y ) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling "PROTECTION FROM CONTAMINATION" 7'_w�0 ' :�­ ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing '„REQUIREMPNTS FOR LATIONS.Ii"SP);`Ar 1-]21. Food and Food Preparation for HSP F-1 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMIi'ADYISORY�,muur»�.»".�.' i:.» �'. w�u 'usw=mda:�E:'i ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below c by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-z) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(5590..090.0 044)) cited in this report may result in suspension or revocation of X. 25. Equipment and Utensils (FC-4)(590.006) the food establishment permit and cessation of food 6. Water, Plumbing and Waste (FC-9)(990.009) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: + s sso(napecrFomsiaaoc � 1 Inspector's Signature: Print: J PIC's Signature: i7 Print: 3� `�c e Page,_(of ✓Pages r c V s Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F 8 Cross-contamination . I 596.003(A) Assignment of Responsibility*� -I-302.1.](A)(]) Raw Animal Foods Separated from Knowledge* 590.003(B) Demonstration of Cooked and RTE Foods* 2-103.11. Person in charge -duties _ Contamination from Raw ingredients 3-302ll0)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other' 2 590.003(,C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* a licants* 3-302.1.5 WashinE Fruits and Vegetables 590.003(.F) Responsibility 01'A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report'l'o The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reservice of Food- 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning ITTnSafe FOOD FROM APPROVED SOURCE Food" 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container* Sanitization'reu eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.1.3 Shell Eggs* Sanitization Tem eramres* 3-202.14 E&re and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness. 'w 3-202.16 Ice Made From Potable Drinking Water* 4-607-11(A) Equipment Food Contact Surfaces and 5-101.1.1 DrinkingWater from an Approved System* - _ 590.006(A) Bottled DrinkingWatcr* Utensils Clean* li 590,006(B) Water Meets Standards in 310 CMR 22.0` 4-602.11 Cleaning Frequency o1'Equipment Food- Shellfish and Fish Froman Approved Source Contact Surfaces and Utensils* 4702.1 t Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from,NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re Mato Authorit 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices g Receiving/Condition 2-401.1 I Eating.Drinking or Using Tobacco* 3-202.11 PHFs Receiver)at Proper Temperatures* 2-401.L2 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-30112 Preventing Contamination When Tasting" 6 Togs/Records:Shellstock I2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained" Ent to ces* Tags/Records: Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacifies* 590.004(7) Labeling of Ingredients* _ 5-204.11 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibilit O ration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processin Methods* Devices 3-502.12 Reduced ox en lacka 'ng,cciteria* 6-301.11 Fhiudw&shing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6-301.1.2 Hand DrvimProvision Denotes critical item in the federal 1999 Food Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: 'Lq 1 Sa �j,, rJ Date: O Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/ PLAN OF CORRECTION " Date No. Reference R-Red Item Verified PLEASE PRCLEARLY / i. _ v /v INT 5. ne cT QM A "1 v - 11 16 Ilk- r9cs��a . ► � � L ., I I a ,t t e i - t Discussion With Person in Charge: Corrective Action Required: ❑ No es I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction violations before the next inspection, to observe all conditions as described, and to Exclusion P e-inspection Scheduled ❑ Emergency Suspension a comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: i 'F 501-14(C) PHFs Received at TemperaWres Violations Related to Foodborne fitness Interventions and Risk Acuording to tau Cooled to - Factors(Items 1-22) (Cont) 41'F)45'17 Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Coolimr Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding -- A-501.16(B) Cold PHFs Maintained at or below 3-20».12 ld toes* 590.(N}4(F) 41%45°F 3-302.14 Protection from Unapproved Additives`__ IS Poisonous or Toxic Substances 4 501 INA) Hot PHF>Maintained at or above 7-WIAI Idunilving ntoroahon-Ou ina; 140E " !•(Ymwnen 3-501 1h(A) �Kua,ts field at or abode lits t".'" - — +li IOZ Com 7- i Time as a Public Health Control r ' mon�'m,e Aoi k,�n+icat +mv" -1 — - ---t ---� '-- _G I Iii. ay +YobhC He;althControi'_� t 7-20 L 11 �Sim(tit n- St+i t c': __ � �- t-- .--)- r — J 10,(l-1r b nana w uirc nano( 7-202.1 i Re t 1ur<m--Yr unce and �-- 7 202.12 Conditions of Use 7-203.11 Toxic Gna nnet�-Prohibition:-`- REQUIREMENTS FOR HIGHLY SUSCEPTIBLE --i POPULATIONS tial l Same ecs t ritcn, Chunk s _ — i 21 , Efil i i i�' U r a,tcurized 1 r� at k 12cd lurcas:md� ?04.1 Z Cht+nic tls f it 41 a hu,. trod!cc cl i! ria'- } Be et s es ,vitb tt aim!+ lapels" 7704.14 �'(�'Ur)��trth gtcrlc trot i+ _ _ t —�SR{7? 17iBr I is Pavtetttvtdts,�` !.705.11 { Im tdc oral } txl contact Lthi Car --- 1 (-501 i I(D)R 4 or{'2tYt,tf, f„e,it i! 9nunn} I'ot#f vnd _' .11 +te a of d sd I'r h+rdc. -l_t a , ) _ Ra t S d i xr us tit t S_c.rtc-.I _ 206.1 l_3 nt:i 1 ;r{ r)-,n ,tct f4vkf r'a�` t ti'ar Rr coed r _0n t t liecti r s, i,:rda 1'.' (:ontrc,.i..S ..} .___ i llunirorin�., CONSUMER ADVISORY � otitooc=3-601I2t rr Cattsu3npticrn of TiMEfTEMPERATURE CONTROLS _ C Proper Cooking Tempel males for JI l F�;,itt: 11 en#c'1Fia r�T„ tndorcu!rkc<;<,r l i i Not c is r'ry*< s n i i1'ullmate i I PHFs _ _ -- loan"d ue 5Ci is 1 6 Il'r c- i 1f;7 13 1 ie,r it i + ,r� 10+-Raw 51,'r1 �Ot,ltt a + 3 C oar nuiu'tnh - i -{ SPECIAL REQUIREMENTS _ i (1.1104r 142! no, ) li � knest - 1 3 1 I.,,) laiu dG1.}itAli ;} � K, iu,, ei ti,, d4tcrts 1 F, iw. t "'atrrt le uwLill', lo(od. t mp,rai v and 3-3011I(0.3r,i C 1',u , tiViid`ori ,i. Sio'tr i Pk F:---'�i i Csict nt aj kitchcri op xi t,ct,5 Irudtfc3 he f z ehi;ed told:^+ Iwo1l las , i , cr'_It f a". i5 i 1 I i -;ly Rt I e,. ; -I i I `"af`yC•.�} it r t rbc ' -utas. I3-_ r ti _._., j i 11 lts le'r I r "!. I7 I �F,tle lin,g tae Hot Holding Vh?).,4TIONS RELkTEt7 70 G0 OD RE TAIL F'R,4CT3CL.3 ry � s tt,5_i if l 1.t i>, {�Pi[i I@7�# 1 C {heft( 23101 1 'tlni(Al e. L If' F=Mire., Stmding ( u r .:L'r r nr r< I +rs ai+ 1 ,1, .a; u c,l17r L-__�� 1 tt' �. _ -. ._ n�crl7 roc it' s rt z-ri �r nor.. irnr trrt7�-tdn,n <. am Gc ray;73.ilif,'} ( rnuncrriflN ho,-sn,,J R I F I,00i- u,;wd;?i tlr 3,, ,t, fb:R ( .-403.11(1 1 Rem rmn,UnsuccdPcaut s ,6iiccl ( ifem Good RetalPractices FC 5Bt7.00G I. "E 1 i 00J Proper Cooling of PHFs ! ,_14 Fara and a.d Proiee s _ FC. s OG;, i--'--4' } ----- 2!5, 1 P meh and.yU_tes„s .. - F-0 t h)L 501A41(A) tin1mgCx. dPHF, I ul1 i Fte 1- r Wate![' - . _ +C _ ' �G p OG3 Wamn 7 1lou and Front I rt i 97 t'_zl ai F s 1,i _ FC 3 007 I to {1 11 L!5 F Within 4 Hiu, f 26 r tsrois r nxrN e , l FC 7 r,<hitHIF 11 dction +mMeiu�� �_ ” 51 ec;alR<y ;r�mEryv 00.9 � r,.mL.iawre ingred,eua<tr 1 i45`F Within 4ikourO X F..4�a17:p-:.1r: -•"'a t:�Y.. R^fr.'i'tiit�'F'#'!i+�:+tl'y+�11'Y'RO it Y.t ;7' -9. n' .v ' a.I" -.w 'Massachusetts Department of Public Health Salem Board Health Division Of Food and Drugs ; Sals ; Sal Washington SStrtreet,4 Floor em, MA 01970-3523 FOOD ESTABLISHMENT�INSPECTION-REPORT !' Tel. (978) 741-1800 Fax (978) 745-0343 Name \' DatQ T e of O eration s T e of Inspection /4 K( D 1 Food Service Routine Address ^ 1 Risk Retail ❑ Re-inspection a a T Level ❑ Residential Kitchen Previous Inspection Telephone 3 -f r❑ Mobile Date: /w j OwnerY/N 1) HACCP ❑ Temporary LlPre-operation J Qfd . n j,r �� L I ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint Ll HACCP Inspector h our]o Permit No. El Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: - Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT_ m s ' ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties :'EMPLOYEE HEALTH El13. Handwash Facilities 'PROTECTIoiJ FROM CHEMICALS " ❑ 2. Reporting of Diseases by Food Employee and PICw . �❑ El 3. Approved Foodor Color Additives 3. Personnel with Infections Restricted/Excluded cc Toxic Chemicals I ❑ FOOD FROM APPROVED SOURCE�,�. am::.;_.. �� .„,;��„, a s 15..( Z TIME/TEMPERATURE CONTROLS-(PotennY all i Hazardous Foods ❑ 4. Food and Water from Approved Source _ ) ❑ 5. Receiving/Condition ❑ 16 Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans a ❑ 18.Cooling f PROTECTION FROM CONTAMINATION:� n rt "'"� r- • " - ''` El 19. Hot and Cold Holding r^;. 20.Time As a Public Health Control ❑ 8. Separation/Segregation /Protection ❑ ❑ 9. Food Contact Surfaces Cleaning and Sanitizing (REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)�,y El21. Food and Food Preparation for HSP El 10. Proper Adequate Handwashing E] 11. Good Hygienic Practices CONSUMERADVISOF,Y,,=-_X­ 22. X 22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below EKE 7K by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 4. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.067) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: �/ Q S.5Mnspw Form 14.tl .. Inspector's Signature: l I Print: Z PIC's Signature: Print: ; PageA_of 7Pages v . I, Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 590.003(A) Assignment of Responsibility' 3-302.1.1(A)(1) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person m charge--duties _ - - - - Contamination from Raw Ingredients 3-302.11(A)(2) Raw Annual Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(,C) Responsibility of the person in charge to Contamination from the Environment require reporting by foal employees and 3-302.11(A) I Foot Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Fad Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge' Contamination from the Consumer 590.003(G) 3-306.14(A)(B) Returned Food and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(F) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Foul" 4 Food and Water From Regulated Sources F 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..111 Manual Warewashing-Hot Water 3-201.12 Foal in a Hermetical) Sealed Container* Sanitization Temperatures* - - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashina Hot Water 3-202.13 Shell Eggs* Sanitization Tent eratures* 3-202.14 &,>s and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable DrinkingWater" concentration and hardness. * 5-101.11 Dunkin Water from an Approved System* 4-601 A I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled DrinkingWater* Utensils Clean* 4-602.11 Cleaning Frequency of Equipment 590.006(B) Water Water Meets Standards in CMR 22Contact Surfaces and Ut nsils* Shelttlsh and Fish from an Approved Sourcece 4-702.1 L Frequency of Sanitization of Utensils and 3-201.14 Fish and Reereadonally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-HotWaterand 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2 301.11 Clean Condition-Hands and Anus* 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.1.7 Game Animals* I1 Good Hygienic Practices 5 Receiving/Condition 2401..11 Eating,Drinking or Using Tobacco* 3-202.11 PHFs'Received at Proper Temperatures* 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Packa a Integrity* Mouth* 3-101.11. Food Safe and Unadulterated* 3-301.12 Preventing Contamination When'Pasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.0(A(Fs) Preventing Contamination from 3-20312 Shellstock Identification Maintained* Employees* Tags/Records:Fish Products 13 Handwash Facilities 3-002.11 Parasite Destruction* Conveniently Located and Accessible - 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.11 Locatin and Placement* ? Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1 6-301.11 Handwashin Cleanser, Availability.2 Reduced oxygen packaging.criteria' b-301.12 Hand Drying Provision 8-103.12 Conformance with Approved Procedures* "Denoles critical item in the fstertl 1999 Fomf Cate ur 105 CtAR 590.000. CITY OF SALEM v BOARD OF HEALTH L Establishment Name: Date: 'aa Page: 3 of Item Code C—Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item ,Verified PLEASE PRINT CLEARLY 1 1 E � 'a 1—IJ`� oo ,n , I i� I t J — Cnid noU i o it ' C-144 P4 40 Avl <-4fu -ate o U I R r d , n n I o r //-- A A C / h4 C7L , 7C�� Discussion With Person in Charge: Corrective Action Required: ❑ No Yes l I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to t Exclusion �inspection-Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that r" S noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo^'W ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: _ / V r-7, So-—1 )4(0— PHFrI Neu rveda—_ t Temperatures Violations Related to Foodborne illness interventions and Risk According to Lav'Cooled to Factors(/tents 1-22) (Cont) 4 1`F/4_51 Within 4 How s. PROTECTION FROM CHEMICALS 3-501,15 Coolim,MlIffiods Por PHFs Food or Color Additives 19 PHF Hot and Gold Holding 3-202,12 Additives'" 3 501.16(B) Cold PHhq Blain irvod at or below 590 0f)-(F 41°745`F 3-302.14 Protection from Ulriappr(yed Addiflyclil` Ic I Poisonous or Toxic SubMancers 1.1 WIN) I lot PHI %fainfameA at or above� WI.IF,— Identifying Intonriation - Otwirri3 140T'. (I aL of .ibovc i 30"F. 1 Common Nalue W,rkjfj�z Coataii),Ir,' I Health control Time as a Public L 47­ 7-20t.li a turn-51'n �— "ou lo(},(Fit 7-2 F)2111 Re,trict;orl flo,scllci.I'-wIll 1,:%l: ------------ ------ _.---- 7 11 Toxic Collfamelz - Prollibl:w POPULATIONS -' REOUIREMENTS FOR HIGHLY SUSCEPTIBLE r '03 7-2(4.11 sallilizeis,Crileri� -ChoresIs 21 I(A) 1:iiplcurif.c.d llre-paial,lcd jrL""(i— TM4.2 (-htnm liti int k hvlo,Vondit ltcvfamii will! N 11, 1 I -IjaAoocntI.Croron ia� Eli, 7SD. ai Is' (0) 1 Kov or llwlall% An incl Fold and 16.1 I lsl,'j '3'prorli,Nl�� Re,irl:!�d UII, Pe�liculer�Clitell'), -0, J'I��- ClIlloil aull ------------- CONSWER ADVISOnY ------l ----- i 2 �i (,o 11 1 gr_iTiFf.-W-ERAT-UR-E CONTROLS- ­--­­-­- ? o,;ai I PropeCooking Tormploalur.,ro for 1 pilivs "IIlk I);jlllTv1W, 1,,rix, ,t�rs'zId 0 WONt,e 1ol KAW fni; I-II,h. t-& ------- -------- P,j, '!REME.N! o, j roo If A'k' gild iloolir"'A ild"iapr% Soloed 1'[1171- lNid 1111,��l 11,4 w h o llpvA1011d ter: dlIhoId urldcr th to 17 Rheating to Hol HId"Iq 0,0LA 7;0ci,4 RELATED TO f,;O(R)RETAVI PRA CTICES T(X;& o 10`iF IWC� --——--------- ovi Ill,dd,w; ;4"D :e 40 1 f:, oOt). -40;.1 1(E,l Rcpla I 11i ill, U,is W,V(. Po-twol,1,!,13,1; 1 hoM Good Retail Prarfices --------- I ma -rl wxi PerEonnei 003 opc-_ .- - -I - - ---------- _T-P—w-per_Coollng of PHFs - ---- 24 f Lx-.0 C(w F-ooltor, C o W4 2,, fr_" 4 401 1 !f A) I Co'lur-,0'loh�d I'll FS o oul 1-9)�Fto I -...... .... 2,l3� I Vi�itol Pti,mtciog d wIisoe 1 FC_ 'r Xo_3 701' Within I four<l,iid Froin M­y i 2i "'M Facil;V C l sljl3 or-I lw, klararI.pis _C- 7 006 501 1.1,113) Coolh,ij,PI IF Mii,,ic Fmoo,Ailthent i 2,1', ­--- ---- --- --- Trnperaurc InoTellm;t,t . ,1�F/45' lfllin,t ll,krrr IkLW In in" _Jff't o"vnIWI "�-- CITY OF SALEM — BOARD OF HEALTH i Establishment Name: ( - Date: Page: of ! Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item Verified ( PLEASE PRINT CLEARLY ff ^ /rn J� rr / r -, _ li , , CA- 4 61 neco ._1 . u,4 4- o _ ,r inj 4-or) r L )(-a C/ 416 J.) 74 KJ na-67 ✓� a O n — -« 6 -------------------- f J Discussion With Person in Charge: ° Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P '�Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that i noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure Ef your food permit. t � ❑ Voluntary Disposal ❑ Other: e y 0 A(C) PHFS Received at'Temperatures P- Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(!tents 1-22) (Cont) -41 Q Fr'45'F Witbi n 4 Hours, 3-501.15 Cooljn�Mahods for Pffp7s-� PROTECTION FROM CHEMICALS Additives 1 PHF Hol and Cold Holding 14 Food or Color 3-202,12 Additms* 3-501.16(B) Cotcl PHF.,Maintained at or below e1JO 0114tF� 41"/45'F* 3-302.14 Protection front linappmVedAddififfe,01 �15Poisonous or Toxic Substances i5iT 1 Identifying infia Ination -011"inal i 1140T. Claaaill-rs �-501 16(A) oast�Held at or above 130F, 1 3, 01111TRAINawt Worl<i 21) Time as a Public Health Conbo( . -- q�2 1 fealth('017aroP I 1 0 al auon-Stu;ake'� lz,,qc600- pjes'nce aod ["e, Condo est of Jwl 202-12 --7 703,1,1 Toxic Qallaiset� - prohN!wiWREOUIREMENTS FOR HIGHLY SUSCEPTIBLE I POPULATIONS(H$ ,04.11 1 Sanitizc1s, crileria -Chelaicak 1: (0J.12 Chentig' 'j,—t,,, ll!odl(�e. 21 es 100 i Uopqieuned Ne-pad:aged Joicand '04,14 Dmn�Arcot ._t rwiia�: Vvarrno.-I I ai�:,Asl 71 2�5-11nt. -- a. s, 1413) 1 o! Pa,t-mi A E,Ips- imm!F(A�d �Ilw or pan�:aD, -('A m ------------- va, St t'd '-prow, 7 1 ------- --—---- Noi ------------ --------------- --- CONSUMER AnV;SNORY TIIWEnEMPERATUR� CON119OL5 i Peeper Cocidnq Fen�pw at for 1 1 -g 15 F -,g SPECiAL ..... 4 V', qfIo, Sf,.,m,n If and al 1w ---------- ------ 'j- —--------- V101"A 170NS RELA TED 4, - - - ! 1 PHI , i6r, Se na-f" be ilq 1ht ow c, f.ud(':>di":i 11, "Wk 3-40", ( k. VC 591111.000 ast�, a cool - 24� �0_xl Pmllectiop 'i ck,: iiaT i PVT 0 -,nt 3nc, f 00� 1 501 NfA) f!ool 1 43'$ to -- ---- 'Nafor,P4�mD;;�c wc I Ftora 1 ),1 i 17 P',,s-a;FafI FC-6 W7 'i 95'F WjWm J, hou 2e� 1 of T�, X, rt; 00,� t i{(iii C i fitiu 11HR,MIr f,zom Ambient J 1 ;-jj'j; tit, i P Commonwealth of Massachusetts City of Salem Board of Health IGmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Dunkin Donuts-Bob Donuts File Number:BHF-2004-000174 282 Derby Street Salem MA 01970 LOCATED AT: 0064 BOSTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0017 Jan 4,2010 Dec 31,2010 $140.00 ESTABLISHMENT Total Fees: $140.00 PERMIT EXPIRES IDecember3l, 2010 Board of Health ) This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4' FLOOR TEL. (978) 741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR DGREENBAUM& ' r.FM.COM DAvID GREENBAtmt, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMIT TO,OPE aA )TE A FOOD ESTAB-L-IIS��H-M7ENNT NAME OF ESTABLISHMENT //��yn4/�S /�q a j ADDRESS OF ESTABLISHMENT FAX# (1 /,X ` -1"41 — ` — MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAME TEL#QI�Nq' -77 1 ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) .� CERTIFICATE#(S)u451' 3(e (Required in an establishment where potentiallyyhhazaa�r(nd'oQuss is prepared) Yblb�b` 1 � 7 EMERGENCY RESPONSE PERSON � � 1 HOME TEL#.a SEZTI Tfiyrsd .:N% n ;5at0ii3 " . HOURS OF OPERATION Please write In thne For examplellani-Illmni iV v TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. {=�$�44220� ------------•-----•----..- .. ------ - -------------•--------------------------------.-......-------------- -----------�yl•-' RESTAURANT ES NO less than 25 seats = (Outdoor Stationary Food Cart$210 25-99 seats =$280 y more than 99 seats =$420 _....... BE hQBgAR KFAST/ YES O -------•-----•-$100--•------- CHILDCARE SERVICES/NURSING HOME-----------------------------•---•-•.---.•.•-•--------------------------- ------------------- ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted In a prominent location in the Establishment In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A,I certify under thep Ins a penalties of penury that I,to my best knowledge and belief,have filed all state tax retiqKand ai list requlr nder t e law. Signature Date Social Se ity or Federal Identification Number Revised 4/24/07 FOODAP2008.adm Check#&Date `" ---;may-------- �. Commonwealth of Massachusetts ` s City of Salem Board of Health KimbedeY Driscoll 120 Washington Street,4th Floor Mayor. SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Dunkin Donuts Anthie's Inc. File Number:BHF-2004-000165 282 Derby Street Salem MA 01970 LOCATED AT: 0282 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0013 Jan 4,2010 Dec 31,2010 $140.00 / WATER SOURCE: CITY ESTABLISHMENT WATER SEWER DISP: CITY WATER Total Fees: $140.00 PERMIT EXPIRES December 31, 2010 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4' FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978)745-0343 MAYOR DCREENBAUM[(,SALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION_ FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT I TEL# 61 /S : /fYl 71( ADDRESS OF ESTABLISHMENT '" O _ _ FAX# qX 'A' 47 5: MAILING ADDRESS(if different) EMAIL-Business': Website: OWNER'S NAME 4 —TEL# ADDRESS STREET C ATE 1111 '',,lWZIP CERTIFIED FOOD MANAGER `i'S NAME(S) ERTIFICATE#(S) ` — CJ (Required in an establishment where potential haze s f is prepay ) EMERGENCY RESPONSE PERSON HOME TEL# � t HOURS OF OPERATION I Please write in time of day. J ( JIt Forexan ellam-11 J TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.fL =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 --•--------------------- ---- RESTAURANT YE 0 Mess than 25 seats = 140 (Outdoor Stationary Food Car:$225-99 seats = more than 99 seats =$420 BED/B . .. T --------------------- O. .. - -------._::.............-...-----------------------------------------$100------- CHLDCARE.aERVICES/NURSING HOME----__•--------------------•--,_:- --------------------------------- ADDITIONAL -----------------------------ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kffchens) YES O $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location In the Establishment. In accordance with the State Sanitary Code, before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Purs ant to MG hapter 6 action 49A certify der the pains penalties of perjury that I,to my best knowledge and belief,have filed all state tax return nd pai t it n e I Signatuk Date Social Security or Federal Identification Number Revised 424/07 FOODAP2008.adm Check#&Date ; a�_P7 est-���.57 $2/0X11 k Commonwealth of'Massachusetts * + a City of Salem Board of health IGmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Dunkin Donuts/Sean's Donuts Inc. File Number:BHF-2004-000163 282 Derby Street Salem MA 01970 LOCATED AT: 0105 NORTH STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0015 Jan 4,2010 Dec 31,2010 $140.00 / WATER SOURCE:CITY ESTABLISHMENT WATER SEWER DISP:CITY WATER Total Fees: $140.00 - - PERMIT EXPIRES December 3I, 2010 { Board of Health !� III This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 T CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4r"FLOOR TEL. (978) 741-1800 IQMBFRLEY DRISCOLI FAX(978)745-0343 MAYOR DCR,ENIIAUM(@SALEM.COM DAVID GREENBAUM, ACTING HEALTH AGENT 2010 APPLICATION FOR PERMI TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT i I &IEL# ADDRESS OF ESTABLISHMENT_ FAX MAILING ADDRESS(if different) EMAIL-Business`. Website: 1 , OWNER'S NAME Ci TEL# C�_7' 1 q' �`I71 ADDRESS STREET Q1CITY - STATE ZIP CERTIFIED FOOD MANAGER'SNAME(S) � I�YO.� O, 1 .IL)� CERTIFICATE#(S)��1WQJ _ (Required in an establishment where potentially hazaMo food is pr pared) 7c EMERGENCY RESPONSE PERSONHOME TEL# 2Sy,� HOURS OF OPERATION ' n Please write in tkne of day. j`�$0a For exam a Ilam-11 piniU TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than I 0,000sq.ft. =$420 _ . ------------------------------------------------- ---------- RESTAURANT ES less than 25 seats 14 (Outdoor Stationary Food Cart$21 25-99 seats = 280 more than 99 seats =$420 ...........•----------------------------- ------------ BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICE$/NUR$IN(�HQME...........................................................................................................---................. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM,YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES O $25 "Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location In the Establishment. In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursue to MGL ipter 62C, action 49A,I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax r ums a p id ate taxes r Ired under the I 1- Si Date Social Security or Federal I ratification Number Revised 424/07 FOODAP20084dm Check#&Date voy 1, Y Commonwealth of Massachusetts 8 City of Salem Board of Health Kimberley Drisooll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 01/04/2010 ESTABLISHMENT NAME: Dunkin Donuts/Drew's Donuts File Number:BHF-2004-000132 2$2 Derby Street Salem MA 01970 LOCATED AT: 0154 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2010-0014 Jan 4,2010 Dec 31,2010 $140.00 / WATER SOURCE:CITY ESTABLISHMENT WATER SEWER DISP: CITY WATER Total Fees: $140.00 PERMIT EXPIRES December-31, 2010----- Board 1, 2010Board of Health i This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 a� pe • CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 120 WASHINGTON STREET,4"'FLOOR TEL. (978)741-1800 KIMBERLEY DRISCOLL FAX(978) 745-0343 MAYOR D(:R1ZNBAUM S T.F.M.COM DAVID GREENBAUIvt, ACTING HEALTH AGENT 2070 APPLICATION --FOR ��PERMIT TO @E T FOOD ESTA�B/LIS1HiMUEN/T� q NAME OF ESTABLISHMENT h�L TEL# QN '1L l ` —'1 i�-1 ] ADDRESS OF ESTABLISHMENT ]` FAX# � ' MAILING ADDRESS(if different) EMAIL-Business': Website: .. r'� 9 OWNER'S NAME TEL# Q,:X -7q4 - 1 �`, �1 ADDRESS STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME( rh V Wen CERTIFICATE#(S) %5S Co CC3 (Required in an establishment where potentially haze ous food• Pre p&ed) EMERGENCY RESPONSE PERSON HOME TEL419&A '(Ss� -7 HOURS OF OPERATION Please write in time of day. For exam e l lam-1 l TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. X280 more than 10,000sq.ft. =$420 .--•-------------------------_...-----------..-------------- -------•- _ - RESTAURANT less than 25 seats $14 (Outdoor Stationary Food Cart$2iES O :25-99 seats 0 more than 99 seats =$420 -------------------YES-_...........N. -•O---------------------.....-.-.-........-----------------...:...........-..----------$---10-------- BEDlBREAKFAST/ 0 CHILDCARE SERVICES/NURSING HOME ..... ............. ............................................................................. ADDITIONAL PERMITS MAKE(not just serve) ICE CREAM,YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit Is not transferable and must be reissued upon change of ownership.The Permit must be posted In a prominent location in the Establishment In accordance with the State Sanitary Code,before any renovations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapte ,Section 9A,I certify under t e pai s and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax 1�sr sand r er i aw. Signa Date Social Security or FiZeral Id ntificati n Number. ------------ - ---- ---------- -- - - Revised 424N7FOODAP2008.adm Check#&Date 5 Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 DATE PRINTED: 01/05/2006 WHO'S PLACE OF BUSINESS IS: Dunkin Donuts File Number:BHF-2004-0132 2$2 Derby Street Salem MA 01970 LOCATED AT: 0154 WASHINGTON STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0319 Jan 3,2006 Dec 31,2006 $100.00 / WATER SOURCE: CITY ESTABLISHMENT WATER SEWER DISP: CITY WATER Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health Page 2 of 5 Commonwealth of Massachusetts s ` City of Salem Board of Health tGmberiey Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Food/Retail Establishment Permit DATE PRINTED: 12/29/2008 ESTABLISHMENT NAME: Dunkin Donuts Anthie's Inc. File Number:BHF-2004-000165 282 Derby Street Salem MA 01970 LOCATED AT: 0282 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2009-0282 Dec 29,2208 Dec 31,2009 $140.00 / WATER SOURCE:CITY ESTABLISHMENT WATER SEWER DISP:CITY WATER Total Fees: $140.00 PERMIT EXPIRES December 31, 2009 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH r1% 120 WASHINGTON STREET,4"'FLOOR -1800 0, _TEL.,(9,78),741 ERLEY DRIS6UI J, ,,�kIkB X(978),,7450343,- A PFAX 014 J MAYOR , Lim JANET DIONNE, Wiwi," ACTING HEALTH AGENT 2009 PILI "I RMI %TkRATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�� �CMI& TEL# 0M 4IIA"A I ADDRESS OF ESTABLISHMENT FAX Ot CM MAILING ADDRESS(if different) EMAIL- Business': nv<-\ Website: OWNER'S NAME ---TEL4 QM :-14A ADDRESS t7U AA A f PIT STREETITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) A CERTIFICATE#(S) (Required in an establishment where polenti I hazardo food is prepared N - - - - C HOME TEL 4 BIB EMERGENCY RESPONSE PERSON_N'. As !!6A bm 1,DAYS OF OPERATION iMonday' '4juesday J:, <Wednesdq -.Thursday Friday 1: Saturday Sunday, HOURS OF OPERATION Please write in timed day. M (For example 11 am-11 pm) INI TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 1 0,000sq.ft. =$420 ......................... ------------ .......................1-1----M-� RESTAURANT YES N less than 25 seats �14O (Outdoor Stationary Food Cart 25-99 seats more than 99 seats =$420 ..................................... ----------------------- -- ----------------------------------------------------- -------------------------------- BED/BREAKFAST/ YES $100 CHILDCARE SERVICES 0; ---------------------------------------------------------------------------------------------------------------------------- ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49A, I certify under the pains and penalties of perjury that 1,to my best knowledge and belief,have filed all state tax returns and paid all state taxes required under the law. log LEI Signature Date See or Federal identification Number Revised 4/24/07 FOODAP2008.adm Chwk#&Date $ ^tvi,•�>+_ "' , .a .4..,,. 'W4M'bws..,+la0i#..f:t.4yYyy,E.w.•+IM•. ^...,/!.K"r"P0."t'( °-ry Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4t"Floor g Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT . Tel. (978)741-1800 Fax(978)745-0343 NameDate T e of Operation(s) Type of Inspection � I t. Food Service ®® Routine Addre n y `Riskt t r�..Retail ❑^Re-inspection Level u Residential Kitchen Previous Inspection Telephone < ❑ Mobile Date: Owner v HI Q, ACCP YM ❑ Temporary ❑ Pre-operation ❑ Caterer ❑Suspect illness Person In'Ch6*g (PI0) Time ❑ Bed&Breakfast ❑ General Complaint in: ` [IHACCP Inspector C t/ { Out: WPermit No. ❑ Other res a -e>tpianation on the narrative page(s)and a citation of specific provision(s)violated. Each viollatidn.;;�MD-b fAul Non-compliance with: Violations Related to Foodborne Iii s interventions and Risk Factors Anti-Choking „Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) © 590.009(F)�� action.as determined by the Board of Health. N'FOOD PROTECTION iIAANAGEM � F �ENT f A I C] 12. Prevention of Contamination from Hands O "-- ❑ 1 PIC Assigned!Knowledgeable I Duties A3. Handwash Facilities g EMPLOYEE HEALTH a '`wnff� ��p�'*' .'"`'� F i 1 s� ""'' r:��.,:`"i C FROM GYIEMiCALS s" ' at ':n 1i °"�i xtt r l'�"`- � ❑ 2. Reporting of Diseases by Food Employee and PIC � ��- ----_11�A __�," =RRL -� ❑ 14 Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded /� s� E1 ❑ 15 Toxic Chemicals Q �FDpD FRgM A„PPROYEp SQURCE Tt , fNTRdeLS ,,.❑ 4. Food and Water from Approved Source IMEREfAURtpote1f1 Hazardousfoods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures El6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating C] 7. Conformance with Approved Procedures/HACCP ❑ 18.Cooling ACCP Pians 9 PROTECTION FROM CONTAMtNATl6t4 "a r,, "w" ""' -I [119.Hot and.Goid Holding [1 ® 8.Separation/Segregation(Protection ��4.. 20.Time As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing ' t�f/ REUIREMENT3 FOR HIGHL` S_SCEi!TIBL i?OPUt AtI,ONS(HSP) E:1'21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El11.Good Hygienic Practices 'GONSUMERADVISORY,� e .'u=; w.a..� a�'r ❑22. Posting of Consumer Advisories Violations Relates to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items chocked indicate violations-of 105 CMR of Health. ..-590.000/federal Food Code.This report, when signed below C" by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-4)(590.0054))) cited in this report may result in suspension or revocation of 25. Equipment and tJtensiis {Fc-a)(5so.005> the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF R&iNSPECTiON: 5,5901ia"pectFam,B-14 tloc Inspector's Signature: Print: PIC's Signature: '� tlJ Print J n l`7 Page�of l' es 3jU L Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT_ S Gross-contamination . 1 590.003(A) AssignmentofResponsibility` 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 Person in charge-itches Contamination from Raw ingredients 3-302.11(A)(2) Raw Arnmal Fonds Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* a ilictmts* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge, Contamination from the Consumer 590.003(G) Re)orung by Person in Charge* 3-306.14(A)(B) Returned Foal and Reservice of Food* 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrict ons Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fps` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501..1.1 I Manual Warewashing-Hot Water 3-201.12 Food in a Hermetically Sealed Container" Sanitization Tent eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-Hot Water 3-202.13 ShellEa s* Sanitization Temperatures* 3-202.Wj,�s and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water' concentration and hardness.* 5-IOL 11 Drinking Water from an Approved System' 4-601ll(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean- 4-602.11 Water Meets Standards in 3 10 CMR 22.0* 4-602.11 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-70311 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Iisted Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re utafo Authority2-301.11 Clean Condition-Hands and Arms* 3-202.18 ShellstockIdortificationPresent* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 1.1 Good Hygienic Practices 5 Receiving/Condition 2-401.11 Eatin ,Drinking or Using Tobacco* 3-202.1.1. PIFs Received at Proper Temperatures* 2-401.12 Discharges From the Eyes, Nose and 3-202.15 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting' Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained* Em ilo ers* Tags/Records;Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.1.1 Location and Placement* q Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxo en tacka 'mg,criteria* 6-301.11 HandwashmR Cleanser, Availability 8-103.12 Conformance with A. roved Procedures* fi-301..1.2 Hand.Diving Provision -Denotes critical item in thefederal 1999 Mal Code•r 105 CMR 590.000. } CITY OF SALEM k j ' BOARD OF HEALTH Establishment Name:-1 U'lm�t an,. .. \XmIAJ o e n Date: Page: of jltem-� Code Refer n e�, R=Red Its � f �� DESCRIPTION,SOF VIOLATIONS/PLAN O�F„CORREC,;TION r4, x� 'yeffied. '- b`s, -� 'a PLEASE PRINT CLEARLY " "!' "n 1 n fl n; �4 Orn- cM , 1l�rl PM a,t., �r%O -?,,,2A h U f oyA on;,/ On SSC :OA� .a 1, BAR 0 s ,�/?renA� o_1ts�r . ,\_r,n He/�,�1 (Xlhn nn�� E�'h� o l,r �! v `n�tT A, n J-e-4 AA n n.t O . n0R _�Y.t <n,c. .��,.� /�nn,..r-� I /,A) V��P tam .( XJJ /� Cl ice,. 7 iM..i YJ1n ,u r (Y rX�t S --Mo-1P.-t't ( ID ) 1 (' 1 7 Y, P n nv ro 0 ( i D vta� (ln n 1 ,/A AA , , ,,A. C_ .._ . _ * / I O i iA o /`lA a_ It'd nr_ie' _A, (� p AA (Al AA /. -♦/4.'LP.1 C� F . (?o.Q� �DP -\''AOA 9----. X an.i v vu _ — //JJ I � � L'1 � 1/�� Ci r_ Discussion With Person in Charge: Corrective Action Required: La, No a" Yes Voluntary Compliance ❑ Employee Restriction / I have read this report, have had the opportunity to ask questions and agree to correct all N Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled C3 Emergency Suspension comply with all mandates of the Mass/Federal Food Coded understand that ' noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: l PHFs Received at7T Cooled Violations Related to Foodlorne,illness Interifenthens and Risk d According to Law Cooled to Factors(items 1-22) (Cont) 4FF145'FWithin 4Hours*-- 3-50115 C�xlfiri,lWblods for PRFsPROTECTION FROM CHEMICALS L14 ArAditives PHF Hot and Go(d Holding 1-202A2 Adduives'* 3-501�16(1:r) Cold PHFs Maintained at or li&4 3-3024 i4 protection front Un 590,00"(F1 410145`F` _jL a j)pro%ed �dditjves` 3-501.16(,A) flot PHFs Mainained at or above Pot�nous at Toxic Substances 7-101AI Identifying Inflinnation- OnVinal 3-501,16, Roasts Held at or,.AZ�, 5WF coll(aillers" -- A) LA- Time as a Public Health Control 7-102,11 Galnufail',lame--WorkiP1LfaA11"nl'1r'1- 7-20111 S�Para[1011- S10)It�e Time as a fold I ic Health ControV Variances R went --T201111 Restriction -Presence tied Use T202 12 Conditions of ruse i—, -Tolic--Folt-alnel' -pril Ill!i off, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE - --�7 POPULATIONS(H T204.1 I a 7iiii 7efs'Crilet ia-Chenvicels* - -- I LffKL---- 1 3-80 1�11(A) U'lifstaeurizeff Pre-packaged Juices will 7-204.12 Chelificak for Washing lltojlwc.("Incrial L- fieveraees ividi Warnin 7-204,14 Dvlrna&euv: (riteria" 4 111 --.- -801 111fll OsPasteurized F ss Lubj learns' 7-205AL-:� Incidental Fixid Contact. -,— I 3-t()1.11(D) Raw or Partially Cuol,cd Antuna) Fund and E-200 11 Rll�trictcd Vst:T�e'ticltjes�Crritelie 7-206.12 Roilent 3 i Scnions — 0 1�ILIC)- U=t tied�,ix El. 7 206.13 1 racking pfokders. Pelt Control and e served, CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22-T 3-6W 1cea oo�....lot tla'"U'ption of Anonal ftlods'flarc kaw.Undercooked or 16 Proper Cooking Temperatures for L PHFs Not Oflan wise Processed to Eliminate. ,401 1 IA7(I)( l 15�>"F 15 Se, 145V15sec, -302.0 paweurizcd Fg;as subsunve for P'Aw Shell 7i- Connoinwed Fi,1r.Meals& Game Aniulds- I t5�F 15 sec. " 21 nun"folk and r)�,,ef Roast - —SPECIAL REQUIREMENTS ll— - wo(A)-(D) violatiffii-of Section 590,009(A;-(D) in I(A)Q) Rallies, Injected tvlcat�- 155�F 15 �90 catcring. mobi1c."n:1,temporary and see, 3-401.11(A)r3) Poultry,WIdCame, Stunted l' j rcsidenual kitchen operations should Ill-- Sniffing Contanunt;Fish,Meal, debited under theappropriate sections _IL)ultry or kaove� 65'f Is 5bove if related to foodborne illness X Whole-Inusde. Intact Ire-f Steaks interventions and risk factors. Other 145OF 590.009 violationq rebuirot to good retail FaI-I tn2 Raw AowJ Fwds(wl;od In a practices ihould be debited under#29 -11— Microwave 165"J., Special R(X]Llircrfreints. 1, 1(- )(1)(b) .Ail Other PHI,- 1 ITT 1S se,; 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES -3 ii1l I(A)&Q)) In-IF, WIT 15 sec, (Items 23-30) —��17 dira, Crural and non-(rao:al viviahoos, which do ton odate pi Me 740711(B) ,rowavc- 165'F Mi null Stall Me ftedilorne illness wf,,,rventions and riskjacrors limed above, wip be , — 4TT 01 1107) Commercially messed RTE fo<a found in ihe.,joilowmg,aei fiewu of the Food Code and 105 CMR 14(7'F .,9c a(6 3-4f73.11(1 } R411lailint,Lrlsd;ced flortiOns of Becl I7 zastss' 23, nagf-,rqn.tjn sppnal 003 __ ­­_ML and Per _ _ - I 24� Food and Food Prolectioil 1 rc 3 1 004 Proper Cooling of PHFs - --4-- ---- (�rLtArjd teq-ilq 1 F0 -4 005 3-501,14(A) Coolifif-,Cooked PHFs frow 1409,n) 26 W atel, M ------ -Fc-- 7t F it kk n 2 1 four�and Frorn i 0'F 007 ry L94l'F145"FWifinfr4fIow% * 2 -7 '008 Poiscinou6 of Tow bl,teilafs - Flo14(fi) ("ooling PHFs Made From Ambient 29, Moors 009 Terrapeorture Ingredients to 41-F/451F -6, Within 4 Ilotim' *Denotes czaaal Ile")If the folk"oll 190)Food codeor 105 CAR 5T)000. CITY OF SALEM BOARD OF HEALTH Establishment Nam F c1 ate: c;� ^ —C) Page: 3 of -� Item Code C=CNdeatltem DESCRIPTION VIOLATION/PLAN OF CORRECTION„ '"'f Date ` T y = +No �Reterem: 'R—Red Item "^ - �' '� � �' a r = +w =� -:�- - -d ,�`y�„ i= x ;su s A Verified ,.r " '� G ¢• $' " PLEASE PRINT CLEARLY6'` r• q'yv ¢F, aE,.. `chi. .W f. AA o+j ) Y -0 TAr Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ Exclusion violations before the next inspection, to observe all conditions as described, and to ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. 0 Voluntary Disposal ❑ Other: F-VI-11K) PliFsReuivedatTemperaWres Violations Related to Foodborne illness interventions and Risk _ According to Late Cooled to Factors(IJetns 1-22) (Cont.) _ 41"F45'F Within 4 Hours. _ Si)1 15 Carlimr 1\irthods frac PHPs PROTECTION FROM CHEMICALS ?g pt{F Hat and Gold Holding 1�4 - Food or Color Additives Lii -3 Sts' lnrnl Coic(PHI,;Natntainett at or below -20?12 Additives' 340.UOa{F) 41V45`F" 3 V2.14 Protection from Unapproved kddtbves* Jg Poisonous or Toxic Substances 3-561.16{A} Hex PI-Ll c Mainiained at or above 7-tol.'11 Identifying irr ormation-Original 140"F lG h.* --{ 3-StH.lb{A) (toasts Heid at or abovc 13VI,L20 * f Contuners- - 7-102-I't 1 Common Name Workut f.ontainers* _ Time as a Pu67ic Health Control 7-20t,13 Se mauon Statafc i :it)i '19 rime as _ a Public "OnteoI� i-2i)2.SI Resi.ictaon-Frtscnu:andLsu* `90:004(11) Variame,Rc�re went � 7-202.12 Condniom of Ift REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7263-11 ToxieCmtaines Prohth"taionxr POPULATIONS(HSP -204.11 -i'samttzefs Criteria chcllluats 7264.1.2 Chtnuc ala for Sk shin a I ocluce Critutias* 2 i _+-80L!t(A) L'np steurizc,d Pzc pac;:aged Juices:mil lleveiaves with &armn I,abols 7-204,14 Urtin A ents.,Lritc tt'" - _.._ 3$£3t 11( } liuotPasivut^irtc{YrtY** _ Ltc;td ntm Ford Contact, Lnhi twa* 3-8oE i 1(13) Raw or Pail"u r Cwk d Auimai Food and X206.i 1 R titin to 1 t ce Pe ttu@o Crttcn t* �-------- R w Sued ,Ui (+uts lot served r 266.12 R<xlcm B atY St'tuons )-$0f 111E} Liu r reed Ford Packa < 7-'06.'!e Tracking P<owtlers,Pest Control and L—_ .-.-1r.-._____._- ._F'ot Re eerved.� Nonitorin�` CONSUMER ADVISORY _ �223b6_ i I Consumer 4dviso�tt Posted fnrC:(rusam ption of TIMEITEMPERATURE CONTROLS % tmof Fix*71tn seRaw, lawked e. 16 Proper Cooking Temperatures �ot ?Jrv,ist €rxessed to Eliminate _h{ LIiA(1PHFs Eggs 155 F 15 Sc Patho ons * __ _(. Fake hnruit t[c.4u acs. l45 l'15see^ , -382 !3 Pasteuriz�ca Egg.:Substitute for Raw Shell Zo 3I.T(A)(2) l�'-Comminuted I ish .Meats&Game . ... - 1551-* I sec SPECIAL_REQUIREMENTS 3-401A1(B)(1)(2) Pork ndB etkoaet-190 L 121 min* ----- —.— t-- .- -- SSod)08tAi-;D') Violations of Section 590.W9(A)-(D in 3-i0'1.11(r1)t>; Rantc<„ lnjeocd%teats 3 5,F 15 cateringmobile turd, teinporary and 3-401.11(A)(3) Poultry,Wild Gamo.,Stuffed PHIS � residc.nl�al kitchen operations slwuld be Suiffittg C mooing Fish Motu, debited under the appropriate sections 1 oultn v kn es 165"'F 15 sec. ° above if related to ftwdborrtc illness 3-461.It(C}3) Whck inti ;1c 6ttactU'ut Stooks intenentaons and risk factor- Other _ 145"T e, _ 590.W9 violations relating to good retail. 3-491.12 Rev. Annual Foods Coaked in a practices should be debited under#29 - Miciowave I65`F* Special Reguivernoi s. 3-4011'4A)(lyb) All Other PH Fs-- 145`F 15 sec. i7 Reheating for Not Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES~ 3-103AI(A)&(D) PIIFs '165'F 15 sec.:' (itents 23-30) $40317.(B) Microwave- 165°F 2,Nlinutr, Standing Orin,al and non-critrr:aI viotaootta,which do not e26ae to lite Time" _ foodborne illness ouetve.ntiomv and risk fastars lasted above, con be 3-403.1 I(C) Commercially Processed RT Fond- f('unu ire the fottowing sections of the Food Code oval 105 C:YIR 140'F* Sy0_Qs7.:. > r 7#am Good Retail Practices i FC �59Et 400 IS a-A03.i t(E) Rcmrm�tans-lieed Portions oCFiecf CL _ _.. Roasts* h 22 1 hdana me t,and Perscrnnci 0_ 2 ( 003 ; Proper Coolingof PHFs 24 Food son Foal Proiectio i FC-----3" 23 Egutpmeni inti Utens�is _ '-FC 4 005 :3-501 A4A) Coaling Cook i PRFs front 140°F to �26, 1 Water Pli r enQand`N este € FC-5 `I Within r 1 tiro c and From 70"-t" l -a7 Ph75*'a(Fac;ht QFC R 007 r0 _ to 41'F/45 F W thin 4 Hours, ' 2Ct Po;s mous or Tonc Mttenais FG 7 i 008 r3..50114(R) -� Cooling PFIFs Made From Ambicut �4 � Spt�ial R;iu;rernststs�___ 1-� OCi9 1 Temperature Ingredieattsif,41°F/45°F 1,-.36 Dther ___LSVithin 4 Iloa.ns'% ._._.. "i)encies:riticat item in ih:le ler l 191;()Fond Crxle or 105 CNIR 590 600. ,t 41 �r 0282 DERBY STREET Dunkin Donuts & Baskin RobinslAnthie's Inc. City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: Violations Related to Good Retail Practices (Blue Items) 744-4771 Equipment and Utensils FAIL Non-Critical BLUE Owner: Comment:Walk-in freezer has ice accumulation on boxes below fan and on pipes on the fan.De-ice the freezer. Robert and Anthis Jackson PIC: Andrew Jackson Inspector: Elizabeth Salandrea Date Inspected:Correct By: 9/15/2008 Risk Level: Permit Number: BHP-2008-0186 Status: SIGNED OFF #of Critical Violations: 0 Time IN: Time OUT: Urgency Description(s): BLUE: All other violations noted in the 9/8/08 inspection report have been corrected. Violations Related to Good Retail Practices(Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMSO2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 15,2008 ) Page I oft J l Item Status Violation Critical Urgency RED: — Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 15,2008 ) Page 2 oj2 1 s f 0282 DERBY STREET Dunkin Donuts & Baskin RobinslAnthie's Inc. City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION t744-4771 Food Con t Surfaces Cleaning and Sanitizing FAIL Critical ❑d RED Owner: omment: Sanitizer not available at one coffee station; sanitizer provided for that area at time of inspection.Sanitizer of proper Robert and Anthis Jackson cC centration must be available at all workstations at all times. 'PIC: -drawer deli unit next to ovens had a used cream cheese spreader laying on a cream cheese container lid in one of the top Andrew Jackson compartments.All utensils must be washed,rinsed and sanitized between uses and stored correctly. Inspector: PROTECTION FROM CHEMICALS Elizabeth Salandrea Toxic Chem Is eIs FAIL Critical ❑d RED Date Inspected:Correct By: O Comment: Containers of ice melt being stored between dry storage racks across from walk-ins.All cleaning supplies and/or 9/8/2008 chemicals of any sort must be stored separately from food and food storage/paper items. 'Risk Level: TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) Hot and Holding FAIL Critical Q RED !Permit Number: omment:Juice fridge temperature recorded at 45.5°F with inspectors thermometer.Repair or turn down to ensure fridge maintains temp.of 417 or below. BHP-2008-0186 i Status: VIOLATION #of Critical Violations: 4 .Time IN: Time OUT: l Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediatelyorwithinl0 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 09,2008 ) Page 1 oft Item Status Violation Critical Urgency Violations Related to Good Retail Practices (Blue Items) Violations Related to Food anod Protection FAIL Critical BLUE Foodborne Illness Interventions i o ant:Container of hash browns in 4-drawer deli unit uncovered.Cover all food in storage to prevent contamination. and Risk Factors (Require immediate corrective action) all delfleld fridge under box of joss had a personal drink in it. Employee drinks must be stored separately to prevent c tamination. Sa nit had an uncovered container of butter.Cover all food in storage to prevent contamination. mall ic e machinee behind front counter left open.Ice machine must stay closed when not in use to prevent contamination. Equipment and Utensils FAIL Non-Critical BLUE —Comment;Walk-in freezer has ice accumulation on boxes below fan and on pipes on the fan.De-ice the freezer. WVa1 in fridge needs general cleaning/sweeping. 0o containers in 4-drawer deli unit need general cleaning. oolata machine needs general cleaning. - Reinspection in one week, all violations to be corrected. City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Sep 09,2008 ) Page 2 oft 1 ' t Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 't 120 Washington Street,a Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name � /)) p to Type of O eration s Tvoe of Inspection L) /�L I , ,/1 �� l / �� , Food ServiceRoutine ®; Address Risk I ❑ Retail Re-inspection f u ^� Level ❑ Residential Kitchen Previous Inspection Telephone ❑ Mobile Date: Owner -- HACCP YIN ❑ Temporary ❑ Pre-operation )CK) ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: /'a0 ❑ HACCP Inspector ��j�(t i f Out:tPermit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. CFOOD PROTECTION MANAOEMENT. �� a,�..` "'""8 "° ,�„.,,,,, �,,� <._ ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13 Handwash Facilities ......ffis and f PRIYTECTION FROM CHEMICALS¢1;'N' h�`fir : ­ ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals F FOOD FROM APPROVED SOURCE ». �.�6 � - `. ' '�:: ,.9 ._ ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(PateMlaily Hazardous Foods)" 1`"�= ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION-010M CONTAMINATION'r r � t '"," � , r" ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing " tEQUIREMENTSFORHIGHLY 9t)SCEPTtB4EPppuLATIDNB(MSP)AV ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing El11. Good Hygienic Practices "WN SUMF ADVISORY" m 1; ,n ❑22. Posting of Consumer Advisories ( Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N) violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(550.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food i 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: I J S:5BJInspecfFortW IO.Ecc i n n I_ Inspector's Signature: ( (_ a Print: PIC's Signature:'�./A ,(n I I,r\ (I l Print: (J I �`! i r1h/JVIC �/ Page Tof Pages \.� _ -_ vc F- Y7 FY y Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination . 1 596.003(A) I Assignment of Res ibility* -- 3-302.1](A)(1) Raw Animal Foods Separated from 590.003(B) Demonsn:ation of Knowledge* - Cooked and RTE Foods* 2-103.11 Person in charge-duties - Contamination from Raw ingredients 3-302A I(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Foal Employee Or An 3-3(A.1 I. Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge* Contamination from the Consumer 590.003(G) Reporting by Person in Charge* 3-306.14(A)(B) Returned Food and Reset-vice of Food* 3 1 590.(103(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590003(E) Removal of Exclusions and Restrictions Food 3-701.1.1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFoal* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.1.11. Manual Warewashing-Hot Water Sanitization Temperatures* 3-201.12 Foci in a Hermetically Sealed Container*in - 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-I-lotWater 3-202.13 Shell Eons* Sanitization Temperatures* 3-202.14 P;_=s and Milk Products,Pasteurized* 4-501.114 Cheltncal Sanitization-temp., pH, 3-202.16 Ice Made From Potable Drinking Wafer* concentration and hardness. 5-101.11 Drinking Water from an Approved S stem* 4-60 LI I(A) Equipment Food Contact Surfaces and Utensils Clean* 590.006(0) Bottled Drinking Water* 4-602.1 590.006(H) Water Meets Standards in 310 CMR 22.0" 1 Cleaning Frequency of Contact Surfaces and Utenten isils"ls'r Food- 590.006(H) and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreaeionally Caught Molluscan Foal Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authority 2-301.1 t - Clean Condition-Hands and Arms* 7202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* I1 Good Hygienic Practices g Receiving/Condition 2-401.11 Eating,Drinking or Using Tobacco* 3-202.11. PHFs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and - 3-20215 Package Inte it * Mouth* 3-101.11, Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em llo ees* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(J) Labeling of Ingredients' 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 -Accessibility;Operation and Maintenance /HACCP Pians Supplied with Soap and Hand Drying 3-502.11 S ecialized Processin Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Handwashin Ctcanser, Availability 8-103.12 Conformance with Approved Procedures" 6-301.12 Hand Drying Provision Denoteg critical item in the federal 1999 Fail Cade or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH 1 Establishment Name: 1/�N61� I/�n� 43 ` ��2 ( /�/�'T' �ilY�r'f Date: / l Cdc. Page: of L Item o Code> C-Critical Item r � s`DESCRIPTION OF,VIOLATION/PL N OF,CORRECTION qv mate No. Reference, R—Red Item: rr verified x , •.�*: -� -r,:. st A--Nuw. �: �...�..✓ '.�.^. to u`K- =s z PLEASE PRINT CLEARLY `.. r L _( J _, 5 `t ,nc Vco t 14 C ' O t^h nrit 0Y' c" I x cJ r I 'Al E i j I V F�r 1\ Cr it �v� I' /-1_ GlrLIC I T : H , Discussion With Person in Charge: Corrective Action Required: ❑ No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction Exclusion violations before the next inspection, to observe all conditions as described, and to )u Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code-4 understand that noncompliance may result in daily fines of twenty_five d��llars or suspension/revocation of C3 Embargo Ll Emergency Closure 1 a your food permit. t� ❑ Voluntary Disposal ❑ Other: 1 t Violations Related to Foodborne Illness Interventions and Risk According to Laik Cooled to Factors(Items 1-22) (Cont) I F/45'F Within -1 Hours, —Cc'Kirin,_,M�,�pds for PHFs PROTECTION FROM CHEMICALS 1=4 L 19 1 PHF Hot and Cold Holding 1-50!.16(B) Cold PHFs Maintained at(it below Addifiv�s,4 590,004F) 41V45"F� 3-302,14 Protection fara_jj!!D!RnLAddtliveS* Poisonous 3-501,16(A) thit PFIFa Manandned at of above 15 _4�_or Toxic Substances — 1 —---------4 Idantihing information 3 5111 1407,--Original 16(A) Roasts Held at or above 130'F ,oil wcer,�" 7102.11 Gumaon,',haae DL Time as a Public Health Control S Da 1-20111 Rortrict;oD-presence and UNs, 7-202.12 Coadiutaas of Use, _1 2�3 [I Connartroo,-Prolabr,onsi REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS{HSP} 7er,,,Criteria-Chcmicals� 204 11 7-2(.412 Chemicals for�V�shu),VrL�dux,Clinefial� 2-1 3-SOI._tl(—A) 1.1imeacurricil Pre-pack aged farces are, 7 2(1-414 In eiit�.Criteriff L freveraces, with ------ -Sol Contact.iAmj icants' —3— lacidernal FeixJ _L_(R_ 3-SOI 11(D) an Pe�dcides,Criantat E7-a06 it R to 5t ' JITIaso'trot Scn,ved 7-206.12 — Radian Bi,il Swuon,�' Hlsl"j 11 Unopened Food Pcacka*r tint T206 1� TiacKing ts.evderi,Pest Control and Re-served. CONSUMER ADVISORY 11MFTEMPERATURECONTROLS I2 -�11 Cauca ner Ad,isory Posted!; r Cinaimptiorof !vdinaj Foods I'hat,are,Raw, Undercooked or 116 Proper Cooking Temperatures for PHFs 1 got Q[h<rh Esc Pru.ertvnd alantin ere 15,5'F 15& . I-,Izs-lr��a_&uc Sor­jc;: i 5,ec, 13 p is'Quylzed ['g,�.;Subsuiule f�a R, S hII �e 3-4012I(A)(2) Comminutod Fish, Meats&6ame Li_ I Animals 155"F 15 sec. ' -401.1 I(B)(I)i2) lor), and Beef Ronst 130�1' 121 nan' SPECIAL REQUIREMENTS 340 1.11(11c)(2) Rtite,� hneoo( TT violutkrw�ca Section 590.0h 190, D (A 4D)in I Sec catoring, rnobile tbodtemporary and 3-401.11(A)(3) liouftry. Wild Game,Stuffed PHFs, rcIrderrlai kil0ren operations sliould tie Sluffrig,Contanditg Fnli,Sled, I debited under the appropriate sec tions Poultry or lkatitc_q1651', l5sec. atio-ve if related to firodtiorne ilhics6 3-40111(0)(3) whklo-musofv,Imact flu,f Steaks Interventions and risk hjcforaOther 14,5IT 590.009 violations relating to good retail ger otic cic should be debited under#29 - Microwave 165'F 3-401,11 -AIR Other ffi.["s-- 145,217 151 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES PHF; 165"P 15 sec, r ((terns 23.30) T103.11(8) Microwave- 165°F2 Mimeo Sum(iing, Crdi,all andnoon-(ritual violdwnj, which do nw ielate',to 1he Time' foodirorne illness ihiervenfions wad t,skfire tore lister!abore, (an be >-403.11(C) Conaryacially Pn:x:eqiiud RTYKNO- 1hcFood Codecued J05CAlR 140 P' 3-403 11(F) Ria lining Ujarwed Portions(if B-cef 690,000 1 i23 j_kh 12uper1je FC -2 pl obs 18 Proper Cooling at PHFs 24 Fooriand Fund Protection FT 5 E 'eat and Ut"ila F 7 4014,ta, 26, PlIxnbri --- 3-501.Jf`.A) ;,Ik..jz Cook PHF, lama, I ...... 7017 Widurr 2 llrajrand From 701F 1 27 Phys,cel FaOlih, FC 6 007 29 1 Poisonous or Tom Materials FC -7 '008 4-- _�7 009 �T�_o1.14(B) C'(witiog PI-IF,,Made From Ambient 26 Special Requirements Temperature hit,reditnts to 41 0045` 17 [30 Oilier _ Within 4 lloors` Ucnotes critical Item Or fl),.Icaera! )999 lo'sCale�r 165 Conti,590000. ``Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4"Floor 9 Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name D to T of Ooeration(s) Type of Inspection n I Food Service ❑ Routine Address ( r -Ris Retail © Re-inspection Level El Residential Kitchen f'�evious I•spection Telephone ` El Mobile Date: ) f Owner HACCP YM El 11Pre-operation 14 ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In:a; [_1HACCP Inspector or Out.2 r7 i Permit No. ❑ Other Each violation c ec ed requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. ''FOOD PROTECTION MANAGEMENT,„ " E, FT ; ❑ 12. Prevention of Contamination from Hands ❑ 1 PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH' " - `� "' z "' ' �'�� r "' `PROTECTION FROM CHL'MICALS" ` +y �;` - 3�. ❑ 2. Reporting of Diseases by Food Employee and PIC 1„ �•-� �� Wa ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals ;o 000DFROMAPP ROVEDSOURCE == „ E_', .„a -10 ❑ 4. Food and Water from Approved Source -TIMEITEMPERATURE CONTROLS(Poterttlaily Hazardous Fovds)17 ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION €,qM�" +� 9' :f , ,14 ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ,. REOUIREMENTS FOR HIGHLY$u dEPTIBLE POPULATI6NS(HSP) s ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY, ,i,, „1`„„ - 1,'�_.�� ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C'. by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(990.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food _26. Water, Plumbing and Waste (FC-5)(590.006), establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007)' {have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(591.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature:t l ( Print: PIC's Signature: <„f-` fl iY-V Q< Print: Page-�orgPages V Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination 1 596.003(7) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B_) Demonstration of Knowledge* Cooked and RTE Foods* 2-103.11 1 Person in charge--dudes Contamination from Raw Ingredients 3-302,1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other- 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washin Fruits and Ve etables 590.003(F) Responsibility Of A Food Employee Or An 3-3(4.11 Food Contact with Equipment and Applicant To Report To The Person hi Utensils* Charge* Contamination from the Consumer 590.003(03) Re ortin b Person in Charge* 3-305.14(A)(B) Returned Food and ReService of Food* 3 590.003(D) Exclusions and Restrictions* _ Disposition of Adulterated or Contaminated - 590.003(E) Removal of Exclusions and Restrictions Food 3-701,11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* 4 1 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111. Manual Warewashing-HotWater 3-201.12 Food in a Hermetically Scaled Container* Sanitization Tem eratures* - 3-201.13 Fluid Milk and Milk Products* 4-501.11.2 Mechanical Warewashing-Hot Water 3-202.13 Shelf Eons* Sanitization Temperatures* 3-202.14 E<=>s and Mitk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness.* 5-101.1 t Drinking Water from an Approved roved S stem.* 4-6011'1(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.07' 4-602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11 Frequency of Sanitization of Utensils and Shellfish 3-201.14 Fish andfish*Reereadanally Ought Molluscan Food Contact Surfaces of Equipment* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* to Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Regulatory Authori nsT 2.301.11 Clean Condition-Hands and Art 3-202.18 Shellstxk Identification Present* 2-301.1.2 Cleanin Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* f.l Good Hygienic Practices $ Receiving/Condition 2-401AI Eating,Drinkin.-or Using Tobacco* 3-202.11 PHFs Received at Proper Temperatures* 2401.1.2 Discharges From the Eyes, Nose and 3-202.1.5 Package Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* b Tags/Records:Shellstock LL2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstoek Identification Maintained* Em llo gees* Tags/Records: Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 5-203.11 Numbers and Capacities* of Ing 3-402.12 Records, on and Retention* 5-204.1.1 Location and Placement* 540.004(7) Labeling of Ingredients' ? Conformance with Approved Procedures 5-205.11 Accessibility.Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.1.2 Reduced ox en Eackaging,criteria* 6-301.11 Handwashing Cleanser,Availability 8-103.12 Confo mance wi h A toted Procedures* b-301.1.2 Hand Dn,Provision ''Denotrs critical item in the federal 1999 Fwd Code or 105 CNIR 596700. CITY OF SALEM BOARD OF HEALTH Establishment Name: Date: Q[9—/09, Page: of CD _J� Item Code C-Critical ItemDate 1 ­ DESCRIPTION OF VIOLATION PLAN OF CORRECTION 4 Date Reference, R-Red Item 1�,- "1 i - I �4' -IL4,PLiASE�P I T CLEARLY U_//4 '(-J- _0LAt)L Discussion With Person in Charge: Corrective Action Required: L3 No Yes I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance 0 Employee Restriction Exclusion 'violations before the next inspection, to observe all conditions as described, and to [a Re-inspection Scheduled L3 Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twdnty-fivQdollars or suspension/revocation of 0 Embargo Ll Emergency Closure your food permit z Yj 110 voluntary Disposal 0 Other: Violations Related to Foodborne Illness Interventions and Risk Ack'orditc,to law I orthall to Factors(Items 1-22) (Cont) I -4 1=Fi45'F Within 4 Hours PROTECTION FROM CHEMICALS - s(—",I 17 _C�xfI i­­o,,1X-T�th o d s for PI IF 19 PHF Hot and Cold Holding 1=4 Food or Color Additives ITAdd , 50 1 1�(B) !;TPHF,,Maintained Eator below -----f an,,,I.. '59o.olwf-) 41°145°F- 3-302,14 Protact ion from I!it ves 3-501 16(A) Hot PflFs zkfaiwai&A, at or above IS PolsondusorT IcSufastances I l4b'F. ContainersA Roams Hold an or above 130,"F Time as a Public Health Central Counniat N� C i02,11 flame cowLi-n—, "Ith Inerl- Tiffic"Ita Public Health 1_1�01.19 I Iallh(crajol, 7-202.11 ,__,0 S�laaauon St2TEL ___ 90.qw(h) Variance I­­--Restrocdon - 7_201.11 Condilionc of Uic, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-2( ,If Toxic Container,-pro Flibrnw� POPULA IONS 0 4.11 Samtivei,,Craci-hk-ClanniciJO {HSP} itcririzrd fric-patJ.aged Juices and 7-20412 Chcnucrf[&for Aash�otloccjAunitt= a 7-204,14 Drrirw,,Axnls,Crireria�, I d, ti, q-So I I I(B) Urc of pa'Tenn nized r-X05-11 7 , n neiderin, 3-801.11(D) I' Peslicides,Criteria, 7�06 1 Regrn, R , Sc tet$gucs Not Serycd. 7-206.12 Rodeol Bait SnaioTo,, - I JiC,, Unije2e,d Food Pacts rr T+Ivt Re-served. 7-206.13 CONSUMER ADVISORY 22 3­60',A1 Con,anner Advism c P(r,,wd far Consumption of TIMEITEMPERATURE CONTROLS (), _ - I Animal I)od, Ran,are llew� Undercooked 0; l.6 Proper Cooking Temperatures for I PHFs Not Otherwiw Processed In Eliminate I 3 ,101 1 IA(1)(2) Fggs- 151'F 15 scv_ _!,�Ih2e�fls �4 "I m_1 Eves-Iminedialc Scrvicc 145'P75sec, 13-307.13 Ito Raw Shell 71;40 LI I(A)(2) comminuted Fith,N4cats& Ganx, Arnantis- lay"F'15 sec, Poik and Beef Rota - 130'F 121 rian, SPECIAL REQUIREMENTS 19 590,(X)9(A)_(D) in Rnfitcs,Iniecled Meats 155T 15 -7 590 f lo (,v) 1))7 loallons ars��7iltin I act catering, mobitic tract,leonporary and 3- 1_11Ckfo) Poultry,Wild Gafne. Stuffed PHFs, leaideiji�al kitchen Operations should be Sniffing Containing Fish:Meal, Uebacd under the appropriate sections Poultry or katiteq-1651, t5 sec. above if I-clatod to ftlodhoriw illncss 3-401.111 Cl13) Whole-mus-le,fmact Beck Steaks iniefvettions' and risk faclor5. Other 145"F 590.009 v io3atwnt relaun,, to-rood retail -4f 1.12 Raw Anunal Fotxk;Cooked Ili a #29 Nlic(owaw 165'F* Special Requirements i-ZIAIG�00) kit Other Plif's-- 145'F 15 sec- I —i [j77 -Reheafing for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 165°F I (ftemi 23-30) i 40-1 11(B) -microcolve- 165'F 2 Minute Standing Craicaland tarn-(rnwal vio,'anomt , which on,Itoi rclene w Ille Time' toodhorni:i1hress inct ventiorviniff risk fastens livied Idrrore, (,in be X403,1 l(C) Commercial Processed RTE Food finaId in aIrrhons of the Food Code and 105("MR 14WFs 6Ot U. item Good Retail Prachham; Remainin",U11,71cc ;crn�)r 'If�Bcef Roasis't 23 1 Management and Personnel F -2 003 1 Proper Cooling of PHFS 24� FoAand Few Prolection, 26, 1 Eq(,�ipnzerjLwjq_ylenrijk; PC 4 '006 tl33 501 14(A) Coolim,Cook(At PHFI, from 14ff�t,—] Lwatol,Pit; I Waste PC- "I----_f�i-2-,Sd— 70'F Within 2 flriurc and From','f)'F 27 Phys,rA Fa Pit PC-6 007 `F Within 4 Hours, C, ous or-0inc Materials PC', 7 008 to tiro 1'F/4 5' 1-14(B) Cooling 1114F�Made Front Ambient 1 special Readrementl 7 _7 Tempe�ratvrc Ingredicim to 4 14-145,1, 130, 1 Ether— "otirs Dtn,'es critical Itur,In ilr [[Mewl 1991)F(axi(,xie or 105 Cklk 590 000, ti I PbRTANT MESSAGE FOR AA'_ 7�ry A.M. DATE �} - TIME //' 11 M liLW_4i//��, 7 OF PHONE q'?'B' X2.5 " AREA CODE NUMBER EXTENSION O FAX O MOBILE AREA CODE NUMBER TIME TO CALL TELEPHONED .:;.. LEASE GALL L i, CANS TO SEE YOUWILL CALL AGAIN WANTS TO SEE YOU RUSH RETURNED YOUR CALL WILL FAX TO YOU. MESSAGE SIGNED FORM 4009 MADE IN U.S.A. NOTES �/,.�� i -. i a Commonwealth of Massachusetts ` .� City of Salem Board of Health IGmberley Driscoll 120 Washington Street,4th Floor Mayor SALEM,MA 01970 Foo&Retail Establishment Permit DATE PRINTED: 01/04/2008 ESTABLISHMENT NAME: Dunkin Donuts & Baskin Robins/Anthie's Inc. File Number.BHF-2004-000165 282 Derby Street Salem MA 01970 LOCATED AT: 0282 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2008-0186 Jan 4,2008 Dec 31,2008 $140.00 / WATER SOURCE:CITY ESTABLISHMENT WATER SEWER DISP: CITY WATER Total Fees: $140.00 PERMIT EXPIRES (December 3112008 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations;improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page-1-of 11 - 'A 3 QTY OF SALEM, MASSACFIUSETTS BOARD OF HEALTH Lbm 120 WAS -IINGTON STREET,4"'FLOOR )e tdhk Y a (978)T741 1000 i,tr ?�V&. .. t.Tk (978);t7".45 ° � stm"•"t r 's5ra1� ;�' r t^x5'x{.�q+�q5'�' MAYOR TsooTTco�sALEia COM JOANNE SCOTT, HEALTH AGENT 2008 �IN1IT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT�`� TEL# ADDRESS OF ESTABLISHMENT ��of u �� t FAX# MAILING ADDRESS(If different) EMAIL-Business': ebsite: t-1 OWNER'S NAME \ "VP TEL# ADDRESS STREET CITY •+��p� STATE ZIP CERTIFIED FOOD MANAGER'S NAMES) �X Ch W /lJ\ CER IFICATE#(S) (Required in an establishment where potent'i(alllyy hhaz�ardou`s'f"000dd iss pr„e aredd))-0� EMERGENCY RESPONSE PERSONJL Ute, ” ` \ TEL# DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunda HOURS OF OPERATION 1 Please write in fine of day. For example Ilam-11 m TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$70 1000-10,000sq.ft. =$280 more than 10,000sq.ft. =$420 ---------------------- --------------------- --------------------less----tth--...... seats --- i6 40 - - P,ESTP.URANT NOd — an 25 1 (Outdoor Stationary Food Cart$21 YES 25-99 seas = 280 more than 99 seats =$420 - --------------------------------------------------------- ----- --------------------------------J-------------------------------..................... ' BED/BREAKFAST/ YES NO $100 CHILDCARE SERVICES ................................................ ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT/SOFT SERVE YES $25 TOBACCO VENDOR YES $135 ALL NON-PROFIT(such as church kitchens) YES NO $25 `Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership.The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C,Section 49 I certify under the pains and penalties of perjury that I,to my best knowledge and belief,have filed all state tax rns and s es qui and e w Signature Date or Federal Identification Number -----------'------ ---'------ --------- - - ---- ------------- Revised 4/24/07 FOODAP2008.adm Checkk&Date -' - -- $ l -r 0282 DERBY STREET Dunkin Donuts & Baskin Robins City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-4771 Handwash Facilities FAIL Critical RED Owner: Comment:There was no hot water in the employee restroom. Restore hot water to a minimum temperature of 110°F immediately. Robert and Anthis Jackson GENERAL COMMENTS: PIC: Anthie Jackson All other violations cited in the 6/18/07 inspection report have been corrected. Inspector: David Greenbaum Date Inspected:Correct By: 6/25/2007 Risk Level: I Permit Number: BHP-2007-0167 Status: SIGNED OFF #of Critical Violations: 1 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 25,2007 ) Page I oft ,f Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 25,2007 ) Page 2 oft k 0282 DERBY STREET Dunkin Donuts & Baskin Robins City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-4771 Food Contact Su es Cleaning and Sanitizing FAIL Critical ❑d RED Owner: ment:There is no sanitizing solution available at the sandwich area or bagel area. Sanitizing solution of proper concentration Robert and Anthls Jackson must be readily available at all work stations at all times. PIC: Good Hygienic Practices FAIL Critical RED Bob Jackson Co}dment: Employee drinks observed on the back prep table. Employees must eat and drink in a designated area or in the dining Inspector: )f om to prevent cross contamination. David Greenbaum Handwash Facilities FAIL Criticald❑ RED Date Inspected:Correct By: 6/1$/2007 Comment:There was no hot water in the employee restroom. Restore hot water to a minimum temperature of 1'10°F immediately. Violations Related to Good Retail Practices (Blue Items) Risk Level: Equipment an tensils FAIL Non-Critical BLUE Permit Number: mment:The back wood prep table needs a thorough cleaning. BHP-2007-0167 p found stored in the bucket. Clean mop and store mop head down not touching any surface to aur dry. Status: VIOLATION rolling rack in back has an accumulation of food debris. Thoroughly clean the rack. #of Critical Violations: T small average air reach not working. Repair unit to good working order or remove. Time IN: Time OUT: Th elfield Unit in the sandwich area has an accumulation of food debris. Thoroughly clean this unit inside and out. GENE L COMMENTS: Urgency Description(s): Reinspection in one week, all violations to be corrected. BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 18,2007 ) Page 1 oft Ir Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Jun 18,2007 ) Page 2 oft }g,.. Q � -rv-t ^r. '9„ ,.if �Com7nonvY�ealth of Masssbhaset'ts City of Salem �. J s A " e. s s • 4,,' r N s ,e,g,,a.r r.` {" M1 Y" 1i' n. &" �., t ,§ T ` " ti r ' r _ ;IGmberley Dnscoil � " w.�i,*mq$. 3= � 120 Washington Street,4m Floor .r't�w1l.. . �dA'�tti. . fi .•. .o* t`. vt SALEM,MA 01970 Food/Betail Establishment Permit DATE PRINTED: 12/20/2006 ESTABLISHMENT NAME: Dunkin Donuts & Baskin Robins File Number:BHF-2004-000165 282 Derby Street Salem_ MA 01970 LOCATED AT- 0282 DER-BY-STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2007-0167 Dec 20,2006 Dec 31,2007 $100.00 / WATER SOURCE: CITY ESTABLISHMENT WATER SEWER DISP:CITY WATER Total Fees: $100.00 PERMIT EXPIRES December 31, 2007 Board of Health This Permit is not transferable and must be reissued upon change of ownership or location.The permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code,beofre any revonations,improvements,or equipment changes are made,all plans for such must be submitted to and approved by the Salem Board of Health. Page 1 of 1 CITY OF SALEM, MASSACHUSETTS ♦ ; BOARD OF HEALTH FECEI )ED a'" �; � , �-t .� 1Z0 WASHINGTON STREET,4TH FLOOR '�( `+�" `r✓ 't i %�.,,, � `"'t�<' r '"k'' 4 �° � ��,��fl"kBALE�c{VIA01970 " , ~w ,JT a e m. � { ��}'P Qr q Sv T' � aW+ �4 '4"s .s ,, �. " .;�.� s 1 fi5. x i �y 1, ;� ' { FAx 978'745`0343 �� a p': o�5.a Y � CITY OF SALEivt.. . . Kimberley Driscoll WWW.SALEM.COM BOARD OF HEALTH Mayor .JOANNE SCOTT, MPH, RS, CHO HEALTH AGENT 2007 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �JJ I L�) CWyc.�rTEL# 97F- 701 ({77 ADDRESS OF ESTABLISHMENT,�2E9 I)-eZI&Z MAILING ADDRESS(if different) EMAIL--Business': X71"(r 'e J �m lt( 4 C dM Owner's: 66 &'4�iy lt� OWNER'S NAME &Jp'7cf /4,t/7-0/-G `Ile-,41'56 _TEL #-2-7f- 7yY - c/ >7� ADDRESS '2-F7- G4(P4 0/970 STREET CITY STATE ZIP CERTIFIED FOOD MANAGER'S NAME(S) 4 PL 1 -d4Ck o t ) CERTIFICATE#(S) q4(3 qS, :3(, (Required in an establishment where potentially hazardous food is prepared) 9'7 F EMERGENCY RESPONSE PERSON HOME TEL# '7Y`I tf7 J --- -- ---- — — ----- DAYS OFOPERATION Monday TuasUaV Wednesd-- T-utsday FndaV_ Saturday —SunUay_� ROORSOfOPERATION 'q ('/0 /) - - Please write in time of dall. TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than 25 seats $10 25-99 seats - 150 more than 99 seats =$200 - _-------------- -. -_ _-- --- - ---__----- - - ....- ._.....-------- .----- .----- _ - ...---- ._. BED/BREAKFAST YES NO $100 -.... .... ------- ---.--- ---- .... ..... -... -.._._... .... ... - --- --.-------------- -----. ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM, YOGURT, SOFT SERVE YES NO $5 TOBACCO VENDOR YES NO $50 ALL NON-PROFIT(such as church kitchens) YES NO $25 *Please pay total with one check payable to the City of Salem. This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursua to MAChap2C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and belief, have dd at ss and paid all state taxes required under the law, Signature Date Social Sec r ty or Federal Identification Number — — — --------- -- --- --- -- ---- a - -- q. - -s----- Revised lilt"5106 FOODAp2407.adm '7 Check it&Ual�o— - � _ �L U _ � -- t 0282 DERBY STREET Dunkin Donuts & Baskin Robins City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-4771 1 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical RED Owner: Comment:There is no sanitizing solution at the back prep tables. Provide sanitizing solution of proper concentration at all work Robert and Anthis Jackson stations at all times. PIC: The sanitizing solution at the front counter found too weak. Sanitizing solution of proper concentration must be readily available at Andrew Jackson all work)stations at all times. Inspector: Owner must maintain a daily sanitizing log. Log left at time of inspection. David Greenbaum Date Inspected:Correct By: Handwasn Facilities FAIL costal RED 12/11/2006 Comment:There is no hot water in the restrooms. Restore hot water in the restrooms to a minimum temperature of 110"F Risk Level: immediately. GENERAL COMMENTS: Permit Number: 1060:AII other violations cited in the 11/30/06 inspection report have been corrected. BHP-2006-0318 Status: PARTIAL COMPLY #of Critical Violations: 2 Time IN: Time OUT: Urgency Description(s): BLUE: Violations Related to Good Retail Practices (Critical violations must be corrected immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 12,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) C Jnr City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Dec 12,2006 ) Page 2 oft 0282 DERBY STREET Dunkin Donuts & Baskin Robins City of Salem FOOD SERVICE ESTABLISHMENT - FOOD SERVICE Inspection HACCP: ❑ Item Status Violation Critical Urgency Telephone: PROTECTION FROM CONTAMINATION 744-4771 Food Contact Surfaces Cleaning and Sanitizing FAIL Critical ❑J RED Owner: Comment:There is no sanitizing solution at the back prep tables. Provide sanitizing solution of proper concentration at all work Robert and Anthis Jackson stations at all times. PIC: Th sanitizing solution in the 3 bay sink found too weak. Sanitizing solution of proper concentration must be used in the 3 bay Agnes Rivera nk to properly sanitize all dishes and utensils. In The sanitizing solution at the front counter found too weak. Sanitizing solution of proper concentration must be readily available at David Greenbaum all world stations at all times. Date Inspected:Correct By: Handwash Facilities FAIL Critical ❑d RED 11/30/2006 Risk Level: ` Comment:There is no hot water in the restrooms. Restore hot water in the restrooms to a minimum temperature of 110°F w immediately. Violations Related to Good Retail Practices (Blue Items) Permit Number: Food and Food Protection FAIL Critical BLUE BHP-2006-0318 Status: Co ent:The ice cream scoops found in standing water. Ice cream scoops must be stored in running water. VIOLATION Equipment an tens FAIL Non-Critical BLUE #of Critical Violations: omm t:The Blodgett oven needs a general cleaning. 3 Time IN: Time OUT: Pr ide ' ible,accurate internal thermometers in both walk ins. T Beverage air reach in in Baskin Robbins needs a general cleaning. Urgency Description(s): BLUE: T elfeild#3 unit is missing a thermometer. Provide a visible,accurate thermometer in this unit. Violations Related to Good GENERAL COMMENTS: Retail Practices (Critical violations must be corrected 1036:Reinspection in one week, all violations to be corrected. immediately or within 10 days)(Non-critical violations must be corrected immediately or within 90 days) City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 30,2006 ) Page 1 oft Item Status Violation Critical Urgency RED: Violations Related to Foodborne Illness Interventions and Risk Factors (Require immediate corrective action) 7� City of Salem Board of Health 120 Washington Street,4th Floor SALEM MA 01970(978)741-1800 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Commonwealth of Massachusetts ( Rev. Nov 30,2006 ) Page 2 oft ) t Massa,hbsetts Department of Public Health a Salem Board of Health L.4W r.- ) - 120 Washington Street,4'"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name r Date T of 0 erationfs) Type of Inspection J1 a/ c- JPFood Service [,Routine Address ' File ElRetail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspe tion Telephone 4_ ❑ Mobile Date: III(,, 0 r- Owner / HACCP YIN El Temporary El Pre-open a ion i r rS J ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: llj � [IHACCP Inspector o Out; . , {� Permit No. ❑Other Each violation checked requires-in explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. [FOOD PROTECTION MANAGEMENT °� am�.,,,m..,� ,�.,�„�a ,yr„�U ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties [113. Handwash Facilities EMPLOYEE HEALTH ,R .e.d.,.,,,... ,',t� ask� 1'PRdTECTION FROM CHEMICALS ",:...�,�� !, ❑ 2. Reporting of Diseases by Food Employee and PIC _ •"< .ice ' =4 "" __ =taLG '-� �"» ' "_ - �_ . ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15 Toxic Chemicals I FOOD FROM APPROVED SOURCE,„,r':- j 0`,2v aNM y�`ab.�;�, 5' ir- MElTEMPERATURE CONTROLS(potentially H " d 4. Food and Water from Approved Source f TI ( � azardous Foods)� ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements [117. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing ';REOUIREmews FOR HIGHLY Stitdo-tBLEPQPULATtOksolis 1 ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMERADVI§OFiY'„ El 11. Good Hygienic Practices i ❑22. Posting of Consumer,Advisones,u ....» :»:M Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions ❑, immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.0 order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC cited ) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (Fc-s)(sso.00s) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: Inspector's Signature: ` Print: j(-)1kVA ( PIC's Signature: 4�0� Printi11 lZ i-; `/..�f�.(�l' I I }/ l i Page ofPages k� Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT F 8 Cross-contamination 1 590.003(A) Assignment of Responsibility* 3-302.11(A)(]) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge* - Cooked and RTE Foods* 2-103.1.1 Person in charge-duties Contamination from Raw Ingredients 3-302.11(A)(2) Raw Am trial Foods Separated from Each EMPLOYEE HEALTH Other" 2 590.003(0) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.11(A) Food Protection* applicants* 3-302.15 Washing Fruits and Ve. etables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In Utensils* Charge' Contamination from the Consumer 590.003(G) Reporting by Person in Charge' 3-306.14(A)(B) Returned Food and Reservice of Food'* 31 590.003(D) Exclusions arid Restrictions* Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.1'1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Fps` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food ma Hermetically Sealed Container* Sanitization Temperatures* 3-20113 Fluid Milk and Milk Products* 4-501.112 MechanicalWarewashinb Hot Water 3-202.13 Shelf Eons* Sanitization Tempe atures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. 5-1.01..11 Drinking Water from an A roved S stem" 4-601.I[(A) Equipment Food Contact Surfaces'and 590.006(A) Bottled DrinkingWatcr" Utensils Clean' 590.006(B) Water Meets Standards in 310 CMR 22.0* 4 602.11 Cleaning Frequency of Equipment Food- Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4-702.11. Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Came and Wtkf Mushrooms Approved by Re ufatoAuthorit 2.301.11 Clean Condition-Hands and Arms* 3-202.18 Sbellstock Identification Present" 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11. PIirs Received at Proper Temperatures* 2-401.1.2 Discharges From the Eyes, Nose and 3-202.15 Pucka e Integrity* Mouth* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records:Shellstock l2 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock Identification Maintained Ern to ees* Tags/Records;Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(7) Labeling of Ingredients' 5-204.1.1 Location and Placement* Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Nand Drying _ 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging'criteria" 6-301.11 Handwashing Cleanser,Availability 8-103.12 Conformance with Approved Procedures* 6301.12 Hand Drying Provision -Denotes critical item in the federal 1999 Foal Cale or 105 CMR 590.000. - CITY OF SALEM # BOARD OF HEALTH Establishment Name: 1) Date: Pager of Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date .E No. Reference . R—Red Item Verified PLEASE PRINT CLEARLY s zo Co r 7 , I I� ¢o vF / l 4 2441 E .F r2 =k ,F `r� P neC, '"1v f t Discussion With Person in Charge: Corrective Action Required: ❑ No es ti I Dave read this report, have had the opportunity to ask questions and agree to correct all oluntary Compliance ❑ E cEmployee lo a Restriction/ violations before the next inspection, to observe all conditions as described, and to El Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five d Ilars or suspension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. n,f^�y , ❑ Voluntary Disposal 0 Other: II I111CAA� cul � ��, f 3-501.14(C} PHFs Recojved at Temperatures Violations Rotated to Foodborne Illness Interventions and Risk According to Iaw Cooled 1'o Factors(items 1-22) (Cont.) 4PF/45'F Within 4 Homs. PROTECTION FROM CHEMICALS 3-50L15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(B) Cold PI•l s Maintained at or below 3-202.12 Additntei* 590.004{13) 41`145°F* 3-302.14 Protection from Ung roved Additives" 15 Poisonous or Toxic Substances 3-501.16(A) Hex PHFs Maintained at or above 140°F. 7-101.11 identifying Information-Origin"I 3-50116(A) Roasts Held at or above 130°F. Containers* 7-102.11 Common Name -Workin3 Containers* 20 Time as a Public Health Control 7-201.11 Se araban-Stora¢e" 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use w 590.004(H) variance Requirement 7-202.12 Conditions of Use` 7-203.1 Toxic Containers-Prohibitions, REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Coterio-Chemicals* POPULATIONS(HSP) 7-201.1.2 Chemicals for Washing Produce,Criterias` 21 3-801.1 i(A) Unpasteurized Pre-packaged haves and Beverages with Warning I.,tibcls* 7-204.14 Drina Agents.Criteria' �. 7-205.11 Incidental Food Contact,Lubricants* 3-801,11(B) Use of Pasteurized Fees' 7-206.11 Restricted Use Pesticides,Criteria* 3-801A 1(D) Raw or Partially Cooked Animal Food and Raw Seed S xouts Not'Served. 7-206.12 Rcx{unf Bait Stations* 3-80'1.11(0 Uno erred Food Packa=e Not Re-server!. _T_206.'13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-f 03.11 Consumer.Advisory Posted for Consumption of Animal Foals That are Raw.Undercooked or 16 Proper Cooking Temperatures for PHFs Not Otherwise Processed to Eliminate _ 3-401.11A(1)(2) Eggs- 155°F 15 Sec. i$ithoaens* e`ecnve;nrmoi B 0s-hvnrediate Service 145°F15sec* 3-302.13 Pasteurized Eggs Sut�stitwe for Raw Shell 3-401.11(A)(2) Comminuted Fish,Meats&Game F s* Animals- 15YF 15 sec:. 3-401.11(13)(1)(2) Pork.and Beef Roast- 130"F 121 min` SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(ll)in sec. * catering, mobile food, temporary and 3-40L 11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultr or Ratites-165'13 15 sec. * above if related to foodborne illness 3-401.11(0(3) Whale-muscle,intact Beef Steaks interventions and risk factors. Other 145'13" 590.009 violations relating to good retail 3401.12 Raw:Animal Foods Cooked in a practices should be debited under 4129- Microwave 165"F* Special Requirements. 3-40111(A)(1)(b) All Other PRFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(ll) PRFs 1650E I5 sec. * (Items 23-30) 3-403.11(B) Microwave-165°F 2 Mhmfe Standing, Critical and non-critical violnnons, which do not relate to the Time* foodborne illness inter vennons and risk faciors listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the fotlomdrrg sections of the Food Code and 105 CMR 14WT- 590.000. 3-403.11(6) Remaining Unsliced Portions of Beef item Good Retail Practices FC 590.000 Roasts` 23. tsfanagemeni and Perso_nn_el _ FC-2 .003 18 Proper Cooling of PHFs 24. Food and Food Protection FC--3 .004 25. Eguipmeni and Utensils FC-4 1 ,005 ---W(A) Cooling Cooked PHFs from 140°F to ------- 3-501. - 26. Waterl.Plumhin and l^laste FC-5 i .006 7017 -- Within -ours and From 7(1 F� 27. Physical Facility FC-6 .007 to 41"F/45"F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 T.008 3-50114B) Cooling PIs Made From Ambient 29_ . S eeial R . utrements _ .008 Temperaame Ingredients to 4l°F/45°F 30. Other Within 4 Hours'" saeon,,,:,nrraz.a�� °Denotes critical nein in lhe.facieral 1999 Food Code or 105 CMR 590.000. Commonwealth of Massachusetts City of Salem Board of Health 120 Washington Street,4th Floor SALEM,MA 01970 DATE PRINTED: 01/05/2006 WHO'S PLACE OF BUSINESS IS: Dunkin Donuts & Baskin Robins File Number:BHF-2004-0165 282 Derby Street Salem MA 01970 LOCATED AT: 0282 DERBY STREET SALEM, MA 01970 Permit Type Permit No. Permit Issued Permit Expires Fee Restrictions/Notes FOOD SERVICE BHP-2006-0318 Jan 3,2006 Dec 31,2006 $100.00 / WATER SOURCE: CITY ESTABLISHMENT WATER SEWER DISP: CITY WATER Total Fees: $100.00 PERMIT EXPIRES December 31, 2006 Board of Health Page 4 of 5 v-�.+�r.6,�n F,a+r.s .,, minw.v{'t _,. 1`•n +�'r�� " .r. R�°� �+r'w.AG.". s4 M�^^ry „'4��fi -.+`- S µ a"M`�.•� "1 ."s.-� �ww`Wri^Rig' r.Y�1ws.+w+ay--:.;ts.•rb+ r�I"�+. 6 ��"�` R+''�1,�j1'e#. Y�, '9K'! i+�1N����i��rT+ r+n,!mp,•v-ny. 'Ttma0;anam•.^'a.+n-q-uh..w.t�'.�yix,r+ 'y% !'i' . , SY`*.w.f T°tv "4m R }'RRS.h. p . S i ..a a.. ,t_fie �� `•+, y, , CITY OF SALEM MASSACHUSETTS "' -• BOARD OFHEALTH . ; , "- :- *w�-'.� :,i - .: - 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 . FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Dunkin Donuts & Baskin Robbins - Anthie's Inc. Address of Establishment: 282 Derby Street Owner's Name: Robert and Anthie Jackson Restrictions: Application Date: 12/22/05 Permit for Food Establishment 165-06 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2006 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. HEALTH AGENT CITY OF SALEM, MASSACHUSETTS BOARD HEALTH STREET, ( s 120 WASHINGTON STREET, 4TH FLOOR SALEM MA 01970 TEL 978-741-1800 DEC 12 2005 STANLEY J"+US CZ' :JR kr ,zar �' + ; ' FAx 978-7450343, r �a , , , F e i ,r n X: ,d i ' "0 , ,. 24ALE°M COMb�3}m "a L f '. 7 t �lil x.Q�ir1SAL�I��" :,! i' iw Fh - MAYOR ,. �,. x,�.�, �a ," 17�BOAb (7F�HELI�kI f��,r . c JOANNE SCOTT, MPR RS;CHO +1 (- ; ar ' , I i a��` HEALTH AGENT ` - "A,'�'r#9 2006 APPLICATION FOR PERMIT TO OPER`A`T_E^A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT �� S �� �bc�.}� n�(iylA/�i,1y1��11,�1 rr71�0'vlc', ,�nJ� ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) o �� �p —1 OWNER'S NAME #G� p« � `1 1 ADDRESS CITY ST TE ZIP CERTIFIED FOOD MANAG R' AME(S) CERTIFIC TE s) - (required in an establishment where potentially h r ous foo-d"Ts prepared.) `n EMERGENCY RESPONSE PE 2EsSON �J TEL# HOURS OF OPERATION: Monl�Tue. - Wed. - Thu. - Fn.� Sat. - Sun. " TYPE OF ESTABLISHMENT FEE (check only) RETAIL STORE YES less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 - - .... ............... - ------ -------- --- RESTAURANT YES NO / / less than 25 seats =$10 [/ lP 25-99 seats = 50 more than 99 seats =$200 - -------------------------------------------------------------...._-------------$---10- ----------------- BED/BREAKFAST YES O 0 - -------------------------------------- ----------------.....------------...-------------......----------------- ADDITIONAL PERMITS MAKE (not just serve) 10E CREAKYOGURT, SOFT SERVE YFc Kin c5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES -NO $25 *Please pay total with one check payable to the City of Salem . This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best knowledge and be f; have filfkd.all state tax returns and paid all state taxes required under the law. Signature Date or Federal Identification Number --------- ------- ------ ----'---- ------- - - -- -- -' Revised 11/03/05 FOOD AP2.adm Check#&Date �D�`� roo ) �` �' `'Y'— fv�e���t�-�S Massachusetts Department of Public Health Salem Board of Health Division of Food and Drugs 120 Washington Street,4t"Floor Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat Type of 0 eration(s) Type of inspection D(' //9 C9 (Z ,® Food Service LlRoutine Address Rik ❑ Retail X] Re-inspection Telephone Level ❑ Residential Kitchen Previous In pectin P ❑ Mobile Date: ��/ Oj Owner HACCP Y/N ❑ Temporary ❑ Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge PIC) Time ❑ Bed&Breakfast ❑ General Complaint cr In: ❑ HACCP Inspector Out° Permit No. ❑ Other Each violation chic d requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities .EMPLOYEE HEALTH El2. Reporting of Diseases by Food Employee and PIC '-PROTECTION FROM CHEMICALS I ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15. Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIME/TEMPERATURE CONTROLS(Potentially Hazardous Foods)," ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP). ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMERADVISORY _. ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practicesd�umm ber of V plated Provisions Related Critical (C)violations marked must be corrected To Foodborrie'll esses Interventions immediately or within 10 days as determined by the Board ` '\ 'sand Risk. Factord(items 1-22): of Health. Non-critical (N)violations must be corrected �;,`'pffici�l'Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board todayj.tlie items checked indicate violations of 105 CMR F Health. �,c �,@)0.q=federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) {bY a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.003 order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 25. Water, Plumbing and Waste (FC-5)(590.005) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address- 29. Special Requirements (590.009) within 10 days of receipt of this order 30. Other DATE OF RE-INSPECTION: \ Cd����� S:5SOInspectFomi6-IG.tloc ' �.. N t Inspector's Signature: Print: i ^ 211 JAr, PIC's Signature: ^ ` Print: P)AQ i . Page of�Pages Li Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT S Cross-contamination I 590003(A) Assignment of Responsibility _ 3-302.11(A)(1) Rat Animal Foods Separated from 590.003(B) Demonstration of Knowledge' Cooked and RTL Foods- 2-103.11 oods*2 103 11 Person in charge--duties Contamination from Raw Ingredients 3-302A l(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(0) Responsibility-of the person in charge to Contamination from the Environment require reporting by food employees and 3-30211(A) Food Proteeflon* a r tlicants* 3-302.15 Washing Fruits wid Vegetable, 5%003(F) Responsibility Of A Food Employee Or An 3-3(14.11 Food Contact with Equipment and Applicant To Report To The Person In Utcnsils'r Charge* Contamination from the Consumer 590.003(G) Re ortin,b,Person in Char e* 3-306.14(A)(B) Returned Focal and Reservice of Food" 3 590.003(D) Exclusions and Restrictions* Disposition of Adulterated or Contaminated 590.00300 Removal of Exclusions and Restrictions Food 3-701..11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCEFoul` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Com !lance with Food Law* - 4-501.111 Manual Warewashing-Hot Water 3-201..12 Food in a lIcnnetieally Sealed Container" Sanitization Pem erasures'= 3-201.1.3 Fluid Milk and Milk Products* 4--501.1.12 Mech:micai Warewashinc F3ut Water 3-202.13 SIMiEves* Sanitization Temperatures* 3-202.14 E es and Milk Prahtcts.Pasteurize& 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness, t` 3-202,16 loo Made'From Potable DrinkingWater* 4-601.11(A) Equipment Food Contact Surfaces and 5-101.11 Drinking Water from an Approved System* Utensils Clean* 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(13) WaterMeets Standards in 310 CMR 220* Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source- 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* She0tish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSPListed Chemical* Sources* 10Proper,Adequate Handwashing Game and WilAuthority Mushrooms Approved by 2-301.11 Clean ConditionHandsand Arms` Re utato Authori - 3-20218 Shellstock Identification Present* 2-301.12 Cleanin-Procedure'" 590.004(C:) Wild Mush ooms* 2-301.14 When to Wash" 3-201.17 Game Animals; 11 Good Hygienic Practices g Receiving/Condition 2-401-I1 Eating, Drodting orUsim*Tobacco, 3-202.11 PI lFs Received at I'ro per Tem eratures, 2-401.12 Discharges From the Eyes,Nose and 3-202.15 Package inteerlt 'Y Mouth* 3-101.1.1 Food Safe and Unadulterated" 3-301.12 Preventing ConiaminationWhen Tasting, 6 TagsiRecords:Shellstock L12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification" 590.004(E) Preventing Contann nation from 3-203.12 Shellstock Identification Maintained" Em� TagsiRecords:Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11. Parasite Destruction* 3402.12 Records.Creation and Retention* . 5-203.11 Numbers and Capacities;" 590.0030) Labeling of Ingredients' [6- -20411 Location ttion and Placcment� 't-1-502 Conformance with Approved Procedures -295-11 Accessibilit} 0 ration and Maintenance/HACCP Plans Supplied with Soap and Hand Drying 3-502-1IDevices 3-502.12 Reducer!oxy>en acka«inecriteria' 30111HandwashineCleanser-Availabilit 8- 3.12 Conformance wi h A proved Pracednres" 301.12 Hand Dryin Prov cion Denotes critical item in the federal 1999 Food Code or 105 CMh 590.000. 1 } CITY OF SALEM BO;Z,6bl OF HEALTH 1 Establishment Name: Dater Page: of_ f item Code C-Critical Item DESCRIPTION OF VIOLATION/PLOLN OF CORRECTION Date No. Reference. R-Red Item :Verified C PLEASE PRINT CLEARLY ' • � G 7 r i . i i k 2 i p f 5 T . Y r 1 S t a. � . . Discussion With Person in Charge: Corrective Action Required: ❑ 'NoI 109,Yes f I have read this report, have had the opportunity to ask questions and agree to correct all Voluntary Compliance ❑ Employee Restriction/ 4olations before the next inspection, to observe all conditions as described, and to Exclusion w ❑ Re-inspection Scheduled ❑ Emergency Suspension Comply with all mandates of the Mass/Federal FoOd Code. I understand that noncompliance may result in daily fines Of twent five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure r your food permit. i ❑ Voluntary Disposal ❑ Other: -€ 3-501.14(C) PHFs Received at'Temperatures Violations Related to Foodborne Illness Interventions and Risk ` According to Law Cooled to Factors(Items 1.22) (Cont) 41'F/45'F Within 4 Homs. PROTECTION FROM CHEMICALS 3-501.15 Coolire,Methods for PHFs --- -- 19 PHF Hot and Cold Holding 14 Food or Color Additives - 3-202.12 Additives* 3-501.16(B) Cold PRFs Maintained at or betook 590.004(F) 41'145'F* 3-302.74 Prot, run from U,ra roved Additives" 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140°F. 7-101.11 Identifying Information-Original 3-501,16(A) Roasts Held at or above 130'F. Containers" ' 7-102.11 Common Name- or n-Containers` 20 Time as a Public Health Control 7-201.11 Se oration-Storaee* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use* 190.004(H) Variance Requirement 7-202.12 Conditions of Use, 7-203.1.1 'Toxic Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizes;,Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chemicals for Washing Produce,Gitene 3-so 1.11(A) Unpasteurized Pre-packaged Juices slid Beverages with Warningl.atbels* 7-204.14 Drying encs.Criteria' o 7-205.11 Incidental Food Contact.Lubricants* 3-801,11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801,11(D) Raw or Partially Cooked Amatil Foodarid Raw Seed S tutu's 'Vol Served.s 7-206.12 Rodent Bait Stations- 3-801.11(C) Unopened Food Package Not Re-served. " 7-206.13 'Cracking Powders.Pest Control and Monitorinn* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for C:oi m rption of 16 Proper Cooking Temperatures for Animal Foocls'I'hat are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1]A(])(2) P.rrg,- 155'F 15 Sec. Patlho�ens " e° �e rrsooi E Ygs-Immediate Service 145'Fldsc'c* 3-31)2.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish,Aleats<&Game Animals- 155'F 15 sec. * - 3-401.11(11)(1)(2) Pork'.and Beef Roast -13WT 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats- 155'F 1.5 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec, * catering, mobile food, temporary and 3-401-1 l(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165'F 15 sec. above if related to foodborne illness -3-401.11(C)(3) Whole-nmscie,Intact Beef Steaks interventions and tisk factors. Other 145°F* 590.009 violations relating to good retail 3-407.12 Raw Animal Foods Cooked in a practices should be debited under#29- Micaowave 165°F* Special Requirements. 3-401_11(A)(1)(b) All Other PHFs-145'F 15 sec.* 11 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PHF,,165'F 15 see.* (Items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing G iticat and non-critical violations, which do not retate to the Time"' foodborne illness iratervanlions and risk fcemrs listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the Food Code and 105 CMR 140"F' 590.000_ 3-4-03.I i(E) Remaining Unsliced Portions of Beef Item Good Retail Practices FC 590.000 Roast"* 23. Mena ement and Personnel FC-2 .003 18 Proper Cooling of PRFs 24, Food and Food Protection FC 3 .004 25, __ Ec�uipmem and Utensils FC 4 .005 _ 3-501,14(A) Cooling Cooked PHBs from 140'F to 2fi Water,Piumbin and Waste FC 5 .006 70'F Within 2 Floors and From 70"F 27. Ph slcai Faeiti FC-6 .007 to 41'F/45'F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 ' .008 3-501.14(13) Cooling Pill's Made Froin Ambient 29. Special Requirements Temperature Ingredients to 41'F/45'F 30 _. Other Within 4 Hours* s it n.ae.za�, �'Denotes critical 1ten)in the],doral 1999 Foal C,)&or 105 CMR 596.000. Massachusetts De p artment of Public Health Salem Board SHealth 120 Washington Street,4'h Floor Division of Food and Drugs Salem,MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(978)745-0343 NameT . e of Ooeration s Tyne of inspection � l ) Food Service t� Routine Address RI k ❑ Retail [IRe-inspection I r Level, A El Residential Kitchen Previous Inspection Telephone N\ ❑ Mobile Date: 10/ �T Owner HACCP YIN ElTemporary C] Pre-operation ❑ Caterer ❑ Suspect Illness Person in Charge{PI ) Time ❑ Bed 8 Breakfast ❑General Complaint c^ In: �i:i� ❑ HACCP Inspector Out: t Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s) violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 59a.oa9(E) ❑ 590-W9(F) ❑ action as determined by the Board of Health. i 1 FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS a ❑ 2. Reporting of Diseases by Food Employee and PIG i. El 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [115,Toxic Chemicals FOOD FROM APPROVED SOURCE - TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) El 4. Food and Water from Approved Source I—- - E] - ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY.SUSCEPTIBLE POPULATIONS(HSP) [121, Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing CONSUMER ADVISORY ❑ 11. Good Hygienic Practices [122. Posting of Consumer Advisories a Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federai Food Code. This report, when signed below 0 iN ' by a Board of Health member or its agent constitutes an )23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing.Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: ' ate' S:S.WI� Fo�-,4d. �J Inspector's Signature: Print: PIC's Signature:, Print: _ �) Page or Pages 1 oior Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 1 Cross-contamination 1 I i90.003(A) Assignment of Responsibility' 3-3.02.11(A)(1) Raw Animal Iooris Separated train 590.003(B) ,Demonstration of Know7ed e*��� Cooked and RPI- Foods* 2-103,11 Person in charge-duties I Contamination from Raw Ingredients 3-30211(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302A 1(A) Food Protection" applicants* 3-302.15 Washin�Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304,11 Food Contact with Equipment and Applicant To Report To The,Person In Utensils* Chaaz,,0 Contamination from the Consumer 590.003fG) Reporting by Person in Charee" 3-306.14(A)B) Returned Food and Reserice of Food* 3 590.003(D) 1 Exclusionsan(diRestricfians'�' Disposition ofAduiterated or Contaminated 590.003(8) Removal of Exclusions and Rcstrictions Food 3-701.11 Discarding or Reconditioning Unsafe FO.OD FROM APPROVED SOURCE Food` 4 Food and Water From Regulated Sources 9 Food Contact Surfaces J90.00G1(A-B) Compliance with Fond Law* 4-501.111 Manual Warewashing-Hot Water 3-201.12 Food in a Her_meticatly sealed Container* Sanitization tetueratures" 3-209.13 Fluid Milk and Milk Products'" 4-501.112 Mechanical Ware-washing-Her Water 3-202.13 Shell Eggs* Sanitization Tem cratures* 3-202.1.4Ea o;and Milk.Products-Pasteurized* 4-501,114 Chemical Sanitization-temp.,pH, concentration and hardness. 3-202,16 Ice Made From Potable Drinking Water" 4-601.11(A) Equipment Food Contact Surfaces and 5-101.19 Drinking Water from an A moved Svstem* Utensils Clean* 590.006(A) Bottled Dcinidna WaeO 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 220'" Contact Surfaces and Utensils* Shellfish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of E ui anent* Shellfish`" 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish Trow NSSP Listed Chemical' Sources'% 1p Proper,Adequate Handwashing Regulatory Authorif Game and L Mushrooms Approved by 2-301.1 I Clean Condition-Hands and Anes 3-202.18 Shellstock Identification Present* 2-301.12 Cieanim,Procedure* 590.004(0) Wild Mus9uxoms* 2-301.14 When to Wash"` 3-201.17 Game Animals* 21 Good Hygienic Practices Es Receiving/Condition 2-401.11 Patin Drinlun or Urine Tobacco* 3-202.11 PHFs Received at proper Temperatures* 2-401.12 Discharges Frorn the Eyes.Nose and 3-202.15 Packagelntemiy* Month* 3-101.11 Food Safe and Unadulterated* 3-301.12 Preventin*Contamination When Tastin=* 6 TagslRecords:Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203.12 Shellstock identification Maintained' Em to gees* _ Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Pwasne,Destruction" Conveniently Located and Accessible 3-402.12 Records Creation and Retention"` 5-203,11 Numbers and Ca a660s* 590.004(7) Labeling of Ingredients" 5-204.1 I. Location aid Placement" 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance /HACCP Plans Suppfled with Soap and Nand Drying 3-502.11 Specialized Processin e Methods* Devices 3-502.12 Reduced oxygen packaging,criteria* 6-301.11 Randwashine Clexnscr.Availability 8-103.12 Conformance with Approved Procedures` 6-301.12 FIand Drvin<*Provision "Denotes,critical item in me fcdrral 1999 Food Code or 105 CMR 594060. CITY OF SALEM BOARD OF HEALTH Establishment Name: r Date: 9 0� Page:-9 - of l .� Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red ItemVerified PLEASE P IN LEARLY- ,< Mo o ' S elZt �f 2kkZt q- /�t o Q - rz L e1_ y -mill/ Y �J . C' * Z f • r f f t i Discussion With Person in Charge: Corrective Action Required: E3 No Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee RestrictionExclusion violations before the next inspection, to observe all conditions as described, and to Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five) dollars or suspension/revocation of L3Embargo ElEmergency Closure i your food permit. -s try t (� � � ❑ Voluntary Disposal ❑ Other: �.J e 3-501.14(0:1 PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1.22) (Cont.) 41'Ft45°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cootav'Methods for PRFs 14 Food or Calor Additives 19 PHF Hot and Cold Holding --- 3-202.12 Additives F 3-501.16(B) Cold PHFs Maintained at or below � 3-302.14 Protection from Unapproved cAdditives* - 590.004(P) 41'/45°F* 15 Poisonous or Toxic Substances -T,5 40'F, !lot PHFs Maintained at or above 40"F. * 7-101.11 Identifying Information-Orio nal 3-501.16(A) Roasts held at or above 130°F. COrltffillerS'" 7-10111 Common Natne-Win kin-Containers* 2g Time as a Public Health Control 7-201.17 Sa araban-Storage` 3-SOLI9 Time as a Public Health Control*' 1-202-I I Restriction-Presence and Use* 590.004(H} - Variance Re uirement 7-202.12 Conditions of Uscm 7-20311 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) 7-204.11 Satutizets.Criteria-Chemicals" _ 7-204A2 Chemicals for Washing Produce,Criteria" 21 3-801.1 I(A) Unpasteurized Pre-packaged truces and Bevectges will,Warning I abelss' 7-204.14 Drvintr. Qents,Criteria* 3-SOI-]i(B) Ii se ofPastenttzect 6zgs* 7-20511 - Incidental Food Contact. C.nbricants* 3-801.11(D) Raw or Partially Cooked Animal Food roll 7-206.11 Restricted Use Pesticides.Criterin Raw Seed Sprouts Not Sewed. r 6.12 Raicnt Bait Stanonsx 3-801.11(C)6.13 Tracking Powders,Pest Control and Monnorin Z. CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 3-603.11 Consumes Advisrnc Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods'Ihat are Raw,Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.1 1A(1)(2) Eggs- 155"F 15 Sec. i'atho�x;ns.'*""`nva uvaoo� E s-Lunrcdrau.Service L45'P-ISsec* 3-30'-,13 Pasteurized Eggs Substitute for Raw Shell 3-401.11.(A)(2j Comminuted Fish,Meats&(lame E gs° Animals- 155'F 15 sec. * 3-401.1 l(B)(1)(2) Pork and Beet'Rtrtst-730°F 121 nrin* SPECIAL REQUIREMENTS 3-401.1 I(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590-009(A)-(D) in sea * catering, mobile food,temporary and 3-401.11(A)(3) Poultry, Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections on try or Ratites-165F 15 sec. * above if related to foodborne illness 7401.11(Ci(3) Whole-muscle,ImactBeef Steaks interventions and risk factors. Other 1450F 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under 1129- Microwave 165°F= Special Requirements. 3-40 1.11(A)(1)(b) All Other PHFs--145'F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED To GOOD RETAIL PRACTICES 3-403.1 1(A)&(D) PHFs 165'F 15 sec. * (items 23-30) 1403.11(B) Microwave- 165 F 2 Minute Staudin i Cr-iiteal and non-critical violations, which do not relate to the Times' ,foodborne iciness interventions and riskJactors listed above, can be 3-403.11(C) Commercially Processed RTE Food- ,found in the following sections of the food Gdde and 105 ClIfh' 140°F* 590.000. 3-403.11(E) Remaining Unshced Portions of,BeeC Hem Good RetaHPractices_ FC 5817.000 Roasts-t23. Mona ement and Psoles el 18 proper Cooling of PHFs 24. _ Food and Food Protection FC-3 .004 _. 25 __Equipment and Utensils FC-4 _.005 _ 3-501.14(A) Cooling Cooked PHFs from 140°F to 26 Water,Plumbing and Waste FC 5 .006_ 70-F Within 2 flours and From 70'F 27. Ph sical Facility____-_ FC-6 ,007 _ to 41.'F(450F Within 4 Hours. * 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Coolmg PHFs Made From Ambient 29. S ecialRe uirements Temperature ingredients to 41°F/45'F 30. Other Within 4 flours:k i m"m azea ''Denotes critical iter in tho,!decal 1999 Food Code or 405 CMR 590.600. a t � i''3,t j4� `' iTt' r .. r +rr-^'y 1 s �.5.-s�+s.e- •irk K `-,�.�rYfyr's�T ,y-w. t ' C[TYOF+SALEM�'MASSACHUSETTS ;;t";BOARD„OF HEALTH 5gr}?_F i Hti 120,WASHIfJGTON�•STREET, 4TH FLOOR .A"4 ,{SALEM, MA 01970 TEL. 978-741-1800 Fax 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Dunkin Donuts Address of Establishment: 282 Derby Street Owner's Name: Robert and Anthie Jackson Restrictions: Application Date: 12/2/2004 Permit for Food Establishment 117-05 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2005 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. q( 1 HEALTH AGENT CITY OF SALEM, MASSACHUS 0 V BOARD OF AEALTH lllU�JJJ 120 WASHINGTON STREET, 4TH FLOOR NOV 3 0 2604 SALEM, MA 01970 TEL- 978-741-1800 CITY OF SALEM 04P FAX 978-745-0343 BOARD OF HEALTH STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT 2005 APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISi ENT NAME OF ESTABLISHMENT_ '(\ �{� �_���_ (� ADDRESS OF ESTABLISHMENT_„ J~ . MAILING ADDRESS (if different) l n OWNER'S NAME ) t TEL# Aq ' q`1 i ADDRESS CITY _ TATEZIP_ CERTIFIED FOOD MANAGER'S NAME(S)^ Wl. AAi ? `" CERTIFICATE#(s) (required in an establishment where potentially hazardous fo d is prepared..) {y„ EMERGENCY RESPONSE PERSON ii8tvt2 TEL# 3 vl HOURS OF OPERATION: Mon.`s Tue>, �\ ad., l�hu� Fri'�Sat._ SunVii TYPE OF ESTABLISHMENT FEE check only j RETAIL STORE YES NO less than 1000sq.ft. =$ 50 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO `� '6 less than 25 seats =P150 25-99 seats more than 99 seats =$200 BED/BREAKFAST YES NO $100 ADDITIONAL PERMITS MAKE (not just serve) ICE CREAM,YOGURT, SOFT SERVE YES $5 TOBACCO VENDOR YES $50 ALL NON-PROFIT(such as church kitchens) YES O $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements,or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that 1, to my best knowledge and belief, have filed all state tax returns and paid all state taxe jar quire�d under the law. Signature ' ate Social Security identification Number -------------- -- &80tea& D--------1---_---- ----------- --------------- Revised 11/03/03 00DAP2.adm #& ateJ 41 �— )a-6 i Massachusetts Department of Public Health Salem Board SHealth p 120 Washington Street,4'" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978)741-1800 Fax(976) 745-0343 Name Date T e of Operatton s T e of Inspection ttl0i &Jolt /! /e I �dl3N„�✓r / / dir Food Service -Routine Address Ris ❑ Retail [I Re-inspection :2-12. &MV X Level ❑ Residential Kitchen Previous Inspection Telephone �/ f44- E] Mobile Date: Owner - HACCP YiN ❑ Temporary ElPre-operation 61r ✓tl�X uN El Caterer F1 Suspect Illness 132/5 e Person in Charge(PIC) Time E] Bed& Breakfast El General Complaint In: ❑ HACCP Inspector Out: Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 596.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ❑ 13.Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14. Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded [115,Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source TIMEtTE6APERATUREOONTROLS{Potentially Hazardous Foods) ❑ 5. Receiving/Condition [116,Cooking Temperatures El 6, Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control ❑ 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing _ CONSUMER ADVISORY ,. .. r. ❑ 11.Good Hygienic Practices ❑22, Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today,the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report, when signed below e ' N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2}(5so.oa3} order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25 . Equipment and Utensils (Fc-4)(590.005) the food establishment permit and cessation of food 26. Water, Plumbing and Waste (FC-5}(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 26. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S.^JOInS dFo. 14,o Inspector's Signature• _ Print: PIC'sSignature: JGadv Print: �•<1t,.rjl /.J(•.J L1P'G' A(r-r. Page of Pages Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination _ 1 59U 003(31 ASsi,*nrnent of Responsibility" 3-302.11(A)(1) Raw Animal Foods Separated from 590,003(B) Demonstration of Kno vW2,e* Cooked and RCL Foods" [:2-j 63,1 1 Person in charge--duties Contamination from Raw ingredients 3-302.11(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* 2 590.OW(C) Responsibility of the person in ch nage to Contamination from the Environment require reporting by food employees and 3-3021 t(A) Food Protection* a lictnts' 3-302.15 WtshinnFruits'and NlVeuetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and ApplicantTo Report To The Person hi Utensils`" Charne" Contamination from the Consumer 590.003(G) Reporting b Person in Charge* 3-306.14(A)(B) Retained Food and Reservice of Food* 3 590.003(1)) Exclusions and Restrictions" Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food" Food Contact Surfaces 4 Food and Water From Regulated Sources 9 590.004 A-B) Compliance with Food Law'" 4-501.111. Manual Warewashing-Hot Water 3-201.12 Food in a Henneticell Sealed Container" Sanitization'Iemeratures* - �-'-- 4-501.112 Mechanical W arewashina-Hot Water 3-201.13 Fluid Milk and Milk Products* b Sani 3-202.13 Shell EE-,-,%* tization Tem sures* era 3-202.13 'Eines and Milk Products.Pastew'ized* 4-501.114 Chemical Sanitization-temp.,pH, concentration and hardness 3-202.16 ice Made From Potable Drinking Water" * 4-661..'11(3) Equipment Fad Contact Surfaces and 5-101.11 Drinkin, Water from an Approved Svstcm . Utensils Clean' 590.006(A) Bottled Drinking Water" 4-60111 Cleaning Frequency of Equipment Food- 590.006(13) Water Meets Standards in 310 CMR 22-0" Contact Surfaces and Utensils* Shelifish and Fish From an Approved Source 4-702,11 Frequency of Sanitization of Utensibs and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* _ Shellfish'" 4-703.11 Methodsof Sanitization-Hot Waterand 3-201.15 Iviolluscem Shellfish how NSSP Listed Chemical* Sources* Ll LL Proper,Adequate Handwashing Game and Wild Mushrooms Approved by nrf 2-301.11 Clean Condition--Hands and!h:mss` Re ulafo Auth 3-202.18 Shelistoc:k Identification Present" 2-301.12 Cleaning Procedure* 540.004(0) Wild Mushrooms 2-301.14 W9ten to Wash* 3-201.17 Game Animals* 11 Good Hygienic Practices $ Receiving/Condition 2-401.11 Fafin , Drinking or Usin,Tobacco* 3-202.11 Flips Received at Proper Temperatures" 2-401.12 Discharges Froin the Eyes.tiose and 3-202,15 Yackaee hue it•" Mouth* 3-101.11 Food Safe and unadul grated " 3-301.12 Preventhm Contamination Whcn Tastin 6 Tags/Records:Sheilstock 12 Prevention of Contamination from Hands 3-202.18 Shellsttxkl'dentificatlon* 590-004(E) Preventing Co aaunination from 3-20112 Shellstockldeati icationMaintained" FT.- Em ees' Tags/Records:Fish Products 3 Handwash Facilities 3--302.11 Parasite Destruction* Conveniently Located and Accessible 5-2 3-402.12 Records,Creation and Retention" . la mes* n 590-004(1) Labeling of Ingredients' 5-20044.11 Numbers and.11 Location and Placement* 7 Conformance with Approved Procedures 5-265.11 Accessibi.htg O eration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 1-502,11 S ecaahzed Processing Methods* Devices 3-502.12 Reduced oxynen aeka«in ,criteria* 6-301-11 Iiandwashhpn Cleanser-Availability 8-,103.12 Conformance with A roved Prrwedures* 6-301.12 Hand Drvin>Pro sion *Denote,critical$em in the federal 1999 Fwd Code or 105 CMR 590.000. CITY OF SALEM BOARD OF HEALTH / Establishment Name: d6W/c/N r906L1#r (4Nf?rPtJ Ae�OP�/rn/J Date: t hi / oy, Page: 2 of 2 Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item - Verified PLEASE PRINT CLEARLY - 2tt C 1311" 444&F I-,ok o 5A_ s cites •+irr s ,c ce 1"r rt—. ptN� c,..w 1"a 14 Ls- 21 � C G.lN'r•K tnr rt.a� t r r-/ u am /Jt2f+4�Ir— <fn/ 2 3 .kf 3 S «r m R � G/rflt r.tb- '�' t�Otf1� 1"K s � oe It e phi tLroi'- euMl G Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion P LI Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of yenty-five dos or suspension/revocation of ❑ Embargo ❑ Emergency Closure rii, your food permit. �G�JLq of Q, ❑ Voluntary Disposal ❑ Other: 3-501.1.4(0) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41'F/45`F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-50t.16B) Cold P1IFs Maintained at or below _ 590.004(F) 4V145° F* 3-302.14 Poisonous cram Unt a .roaed Additives* 3-501 16(A) llot PHFs Maintained at or above 1.5 Poisonous or Toxic Substances 7-101.11 Identifying Inform (4O'Fation-Original :;_507.16(A) Roasts Held at or above 130°F." Containers* 7-102.11 Common Name_-Workinp Containers* 20 Time as a Public Health Control 7-201.11 1 Separation-Stora*e* 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence and Use'" 590M04(H) Variance Re uireu'nent 7-202.12 Conditl ns of Use* 7-203.11 Toxic Containers-Prohibitions" REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers,Criteria-Chemicals? POPULATIONS(HSP) _ 7.204.12 Chenucals for Warfare Produce,Criteria* 21 3-801 A I(.A) Unpasteurized Pre-packaged Juices and Warning L..ibels* 7-204.74 Dr �in Agents.Criteria" Bev,=gos with 7-205.11 Incidents]Food Contact.Lubricants* 3-801..17(8) Lse of Pasteurized Eees* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Animal Food and Raw Seed Spoons Not Served. ,e 7-206.12 Racks Bait Stations* 3-80'1.11(C) Uno erred Fcxrd Parka=e Nor Re-served. v' 7-206.13 'I'ra�kmg Powders,Pest Control and Monitorin R* CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS 22 ',{ 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw, Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11 A(])(2) Eggs- 155'F 1.5 Sec. Pathoo-ens.* Eggs-Immeuh ute Service 145'F75sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted ted Fish,Meats&Game Eggs* Animals- 155'F 15 sec. 3-401.1l(B)(1)(2) Pork a adBecf'Roast-130'F121nim* SPECIAL REQUIREMENTS _ 3-401.1 l(A)(2) Ratites,Injected Meats-155'F 1.5 590.009(A) U) Violations of Section 590.009(A)-(D)in _ sec, 'e catering. mobile food, temporary mid 3-401.11(A)(3) Poultry,Wild Game, Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish, Meat, debited under the appropriate sections Poultr y or Ratites-165'F 15.sec. * above if related to foodborne illness 3-407.11(7)(3) Whole-muscle, haact Beef Steaks interventions and tisk factors. Other 145°F" 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under I/29- Microwave 165'F* Special Requirements. 3401.11(A)(1)(b) All Other PHFs- 145'F'15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) - PHFs 165°F 15 sec. * (Items 23-30) 3-403.11(B) Microwave-165'F 2 Minute Standing Critical and non-critical violations, which do nut relate to the Time° foodborne iliness interventions and risk factors listed above, can be. 3-403.11(C) Commmcially Processed R'rh Food- ,found in the following sections of the Food Cade and 105 CMR 140'Ft 590.000. 3401,11 1(E) Remaining Unsliced Portions or Beef Item Good Refaii Practices_ FC 590.000 Roosts* 23. Masa ement and Personnel _- FC-2 . .003 18 Proper Cooling of PHFs 24. Food and Food Protection__._ FC _23 .004 25 Equipment and Utensils __FC 4 ' .005 3-501.14(A) Cooling Cooked PHFs from 140`F ill 26. W ater,Plumbin and Waste FC 5 .006 70'F Within 2 Flours and From 70'F 27. Ph sical Facility _ FC 6 007 to 41'F/45'F Within 4 Hollis'.* 28. poisonous or Toxic Materials FC 7 0N8 - - 3-501.14(B) Cooling PHFs Made From Ambient 29_ S ectal Re uiremsnis ' .009 Temperature Ingredients to 4l'F/45'P Other Within 4 Hours" *Denotes critical item in the Rderal 1999 Pood Code or 105 CMI)590 000 CITY OF SALEM, MASSACHUSETTS r BOARD OF HEALTH 120 WASHINGTON STREET, 4TH FLOOR SALEM, MA 01970 TEL. 978-741-1800 FAX 978-745-0343 STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO MAYOR HEALTH AGENT COMMONWEALTH OF MASSACHUSETTS PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 305A and Chapter III, Section 5 of the General Laws, to operate a Food Establishment in the City of Salem is hereby granted to: Type of Establishment: FOOD SERVICE Name of Establishment: Dunkin Donuts Address of Establishment: 282 Derby Street Owner's Name: Robert and Anthie Jackson Restrictions: Application Date: 12/15/2003 Permit for Food Establishment 200-04 Frozen Desserts/Ice Cream Permit for the Sale of Tobacco Products These Permits Expire December 31, 2004 This permit is not transferable and must be reissued upon change of ownership or location. The permit must be posted in a prominent location in the Establishment, In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. q"--X�'-Oe / H AGENT CITY OF SALEM, MASSACHUSETi:l TS 111 11 . o 1 ' BOARD OF HEALTH NOV �I�t w 120 WASHINGTON STREET, 4TH FLOOR O 2 B 2.003 SALEM, MA 01970 TEL 978-741-1800, ., - {A FAx 978-745-0343 ' f CITY OF SALEM - .BOARD C)F 1-EFALTH ?:STAN LEY-U SOVICZ -:1Ry JOANNE SCOTT„%MPH RS CHO µ, z t y h �,,MAYORHEALTH AGENT 2004 APPLICATION FOR PERMIT TO I OPERATE A FOOD ESTABLISHMENT NAME OF ESTABLISHMENT TEL# 0(g'_It- 4 ``c'7_7I ADDRESS OF ESTABLISHMENT MAILING ADDRESS (if different) OWNER'S NAME TEL#W txi 3J ^r��In ADD ESS �P`Cy CITY TATE ZIP a _ CERTIFIED FOOD NAGER'S NAME(S) ERTOCATE#(s) (required in an establishment where potentiallyT3zarrd�ous ood pr ared.) EMERGENCY RESPONSE PERSON °r ECL[ �V�UY 7 E TEL#_ oLVI HOURS OF OPERATION: Mon �IOTue.�0. �Wed. \D hu'1��1�Frib��OSatu sun. TYPE OF ESTABLISHMENT FEE check only RETAIL STORE YES NO t � less than 1000sq.ft. =$50 711 ti I UD 3�5 1000-10,000sq.ft. =$100 more than 10,000sq.ft. =$250 RESTAURANT YES NO less than seats 5100 25-99 seats 150 more than 99 seats BED/BREAKFAST YES 10 $100 ADDITIONAL PERMITS MAKE (notjust serve) ICE CREAM, YOGURT, SOFT SERVE YES N $5 TOBACCO VENDOR YES O $50 ALL NON-PROFIT(such as church kitchens) YES O $25 Please pay total with one check payable to the City of Salem This Permit is not transferable and must be reissued upon change of ownership. The Permit must be posted in a prominent location in the Establishment. In accordance with the State Sanitary Code, before any renovations, improvements, or equipment changes are made, all plans for such must be submitted to and approved by the Salem Board of Health. Pursuant to MGL Chapter 62C, Section 49A, I certify under the pains and penalties of perjury that I, to my best kno I belief have filed all state tax returns and paid all state taxes re uired under the law. Signature Date Federal Identification Number ---------- -------- ----------- ----- -------- - ----- ------ -----, Revised 11/03/03- -FOODAP2-.adm--------Check#-&-D ---------- -- -- - --�'x ated }'f!! -n,-A---------------------------------- -13 DS-0 s, r Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4"Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Name S Reg13/K4 DatO� T eoi0 erans Te of Inspectionection dSia t✓ ooe vout Adclksoelfj RiskLJ Retail ❑ Re-inspection one Lev El Residential Kitchen Previous Inspection Teleph 14 ❑ Mobile Date: OwnerHACCP YM ❑ Temporary F-1Pre-operation tir ❑ Caterer El Suspect Illness Person in Charge(PIC) Time ❑ Bed&Breakfast ❑ General Complaint In: El HACCP Inspector v Out: Permit No. ❑ Other Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. FOOD PROTECTION MANAGEMENT - 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties El- - -. 13. Handwash Facilities EMPLOYEE HEALTH PROTECTION FROM CHEMICALS" ❑ 2. Reporting of Diseases by Food Employee and PIC ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded F1_ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE _ _ __ E] 4. CONTROLS 4. Food and Water from Approved Source (Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18. Cooling PROTECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20.Time As a Public Health Control Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP) V9. ❑ 21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices CONSUMER ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions 1j immediately or within 10 days as determined by the Board and Risk Factors (Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR ofC earth. 590.000/federal Food Code. This report, when signed below Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an V. Food and Food Protection (Fc-3)(sso.00a> order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may result in suspension or revocation of 26. Water, Plumbing and Waste (FC-5)(590.006) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S:501nsp fFon 14do F Inspector's Signature: -'�.!'� ,:, �`` f" print: su .� PIC's Signature ".. .may-' ,�- b Print: ...- -� -..?'�',�'..!✓X FIFO/x Pa Pages]a es i � ` r Violations Related to Foodborne Illness interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT K Cross-contamination 1 590.003(A) Assignment of Responsibility' 3-.,02.11(A,)(I) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge" Cooked and RTE Foods* 2-103.11 Person in charge-duties Contamination from Raw hpgredients 3-30111(A)(2) Raw Animal Foods Separated fi-ont Each EMPLOYEE HEALTH Other* 2 590.003(C) Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and - 3-302.111A) Food Protection* applicants* 3-30215 Washing Fruits and Vegetables 590.003(F) Responsibility Of A Food,Employee Or An 3-304.11 Food Contact with Equipment and Applicant To Report To The Person In _ Utensils" _ Charge* Contamination from the Consumer 590.003(6) Re o ting b Person in Charge' 3-306.14(A)(B) Returned Food and Reseprice of Food- 590.003(G) 590.003(D) Exclusions and Resttictions* Disposition of Adulterated or Contaminated a0.003(x) Rcmovai of Exclusions and Restrictions Food 3-701.11 Discarding of Reconditioning unsafe FOOD FROM APPROVED SOURCE Food* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Cam hmeo with Food Law* 4-501.111 Manual Warewashing-Hot Water 3-20L12 Food in a Hermetically Sealed Container* Sanitization Tem eratnres* 3-201,13Fluid Milk and Milk Products* 4-501.112 'Mechanical Warewashina Ilot Water 3-202.13Shc1I Bg s* Sanitization Temperatures" 3-202.14 Eggs and Milk Products.Pastem'izcd* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Iter" concentration and hardness. R 5-101.11 DrinkingWater from an Approved SvAern* 4-601.11(A) Equipment Food Contact Surfaces and Utensils Clem 590.006(A) Bottled Drinking Water* 4-602.11 Cleaning Frequency of Equipment Food- 590.006(B) Water Meets Standards in 310 CMR 220* Contact Surfaces mid Utensils* Shellfish and Fish From an Approved Source 4-70111 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Samti7ation-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by Re ulatort,Authorit 2301.11 Clean Condition-Hands and Acme" 3-202.18 Shellstock Identification Present* 2-301.12 Cleaning Procedure" 5909040(2) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals" 11 Good Hygienic Practices ReceivinglCondition 2-401.11 Eating,Drinking or Using Tobacco- 202.11 obacco*202.1f PHFs Received at Proper Tem pei awres* 2-401.12 Discharges Froin the Lyes.Nose and 3-202.15 Package Ltteufity* Mouth* 3-101.11 Food Safe and Unadulterated'" 3-301.12 Preventing,Contamination Wlpen Tasting* 6 Tags/Records:Shelistock 12 Prevention of Contamination from Hands 590.004(E) preventing Comanin cion from. 3-202.13 Shetls�t�uck Identification* a 3-203.12 Shellstock Identification Maintained* Em kwcas* Tags/Records:Fish Products 13 Handwash Facilities 3-402.11 Parasite Dest action* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* Labeling of Ingredients' 5-204.11 Location and Placement* 590.0040) g g 7 Conformance with Approved Procedures 5-205.11 Accessibility,Operation and Maintenance. /HACCP Plans Supplied with Soap and Hand Drying 3-50211 Specialized Processing Methods* Devices 3-502.12 Reduced oxygen packaging,criteria" 6-301..11 Handwashing Cleanser.Availability 3-103.1.2 Conformance with Approved Procedures* 6-301,12 Hand Drvim,Provision "`Denotes critical item gig the{adoral 1999 Food Code or 105 CN1R 590.0!16. CITY OF SALEM 14 //1� BOARD OF HEALTH Establishment Name:u/Ny+1f Otytrl/dAPAo-I MRldi,us Date: ��Z7/ Page: of Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R—Red Item Verified PLEASE PRINT CLEARLY 2ArcAAFUr A rrA Covst_ tL 0 K6 C 14& 7adzo,pr rA,v A"O O /VS/ c f 4A NIX C 0 2 /�( 0441IL&AX 0 tsar- or– 0104.6* 7. de v 044"Ay ' C 2 C t✓ X-v ASIT A TrOW&02 VP o f!C 141 ), A 4r SIL k M AA ft u APK/ f fF b fd OK CO ir—osDs dOv�so�- Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food.0666. 1,understand that --�. noncompliance may result in daily fines of tw��e ty�=fIII ve:dollars-ars-ot'suspenslon/revocation of LlEmbargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: - f' 3-5(N.34(C) PRFs Received at Pernperatures Violations Related to Foodborne Illness interventions and Risk According to Iaw Cooled to Factors jftems 1-22) {Cant.} 41'FI451F Within 4 Hours.- PROTECTION FROM CHEMICALS 3-501.15 Cooling Methods for PHFs 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-2012 Addtnses''- 3-50t.16(B) Cold PHFs Maintained at or below . 590.004(h� 41'/45' F* 3-302.14 ProtccUon from_Unahproved Additives* 3-501.ICi(A) Hilt PHFs Ivlaintained at or above 15 Poisonous or Toxic Substances 40'F Containers'7-101.11 T nteinformation-Original 3-501.16(A) Roasts Held at or above 130'F, rs 7-102.11 Common Name--Workim>Containers* � Time as a Public Health Control 7-201.11 Se.aration-Storage' 3-501.19 Time as a Public Health Control* 1-202.11 Restriction-Presence and Uae's 590.004(H) Variance Requirement 7-202.12 Conditions of L,,,,- 7-203.11 Toxic Containers-Prohibitionsr REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizeis,Criteria-Chenrieals" POPULATIONS(HSP) 7-204.12 Chemicals for Washia¢Produce,Criteria* 21 3-80111(A) Unpasteurized Pre-packaged Juices and 7-204.14 Drvintr e gut's.Criteria* Beverages with Warning Iabels* 7-205.11 Incidental Food Contact Lubricants* 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides, Crlcenn* 3-801.11(D) Raw or Partially Cooked Animal Food and 7-206.12 Rodent Bait Sfauons* Raw Seed S rronts Not Served.* 7-206.'13 Tracking Powders,Pest Control and 3-801.11(C) Unopened Fund Package Not Re-served. CONSUMER ADVISORY TIME/TEMPERATURE CONTROLS ?2 3-603.]I Consumer Advisory Posted for Consumption of Animal Foods'lfiat are Raw,Undercooked or Ifi Proper Cook ng Temperatures for PHFs Not Otherwise Processed to Eliminate 3-401.1.1A(I)(2) Eggs- 155 F 15 Sec. Pathogens."cir�ave+.vsooi Eggs-Immediate Service 145'Fl5sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3-401.11(A)(2) Comminuted Fish, Meats&Game E s* Animals-155'F 15 sec.* 3-401.11(B)(1)(2) Pork and Becf Roast- 130'F 121 rat* SPECIAL REQUIREMENTS 3-401.1 t(A)(2) Ratites,Injected.Nleats- 155'F 15 590.009(A){D) Violations of Section 590.009(A)-(D)in sec. * catering, mobile food, temporary and 3-401.11(0)(3) Poultrv,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Points,or Ratites-165°F 15 sec. * above if related to foodborne illness 3-401A1(C)(3) Whole-muscle,Inuset Beef Steaks interventions and risk factors. Other 145°F* 990.009 violations relating to good retail 3-401.12 Raw Around Foods Cooked in a practices should be debited under#(29-- Microwave 165°F* Special Requirements. 3-40I A I(A)(1)(b) AR Other PHFs-145-F 15 sec * 17 Reheating for Foot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)& PFiFs 165'F 15 set. * (7terms 23-30) 3-403.11(B) Microwave- 1.65°F 2 Minute Standing Critical and non-critical violations, which do not relate to the Timesfoodborne,illness into venlions and risk factors listed above, can be 3-403.11(C) Commercially Processed RTE Food- foxmd in the fntlnu2rig sections of the Food Code and 105 CMK '140'F* 590.000. 3-403.1.1(E) Remain ng Unsheed Portions of Beef item Good Retail Practices FC 590.000 Roasts^' 23. Manu ementand Personne_IFC-2 .003 1$ Proper Cooling of PHFs -24. Food and Food Protection __ FC-3 .004 __ 3-501.14(A) Cooli25ng Cooked PRFs from 140`'F to 26 __ Water. Plumbin Equipment and Utensils FC 4 .005 and Waste FC-5 Ooh 70'F Within 2 1-Iours and From 70'F 27. Ph deal Facility FC-6 .007 to 41"F145'F Within 4 Hours.* 28. Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling P1[Fs Made From Ambient 29 S eciai Re uirements .009 Temperature Ingredients to 41°F(45 T 30 __ Other Within I Hours'x ss9nronnxe6-x.ax Denotes cra cal item in the fmci it 1999 Food Cone or 105 CMR 590008. R Massachusetts Department of Public Health Salem Board of Health 120 Washington Street, 4`" Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Date T e'of Operation(s) Tv[R of Inspection /^�n1U7�S i, !NS /-Oe�7 Food Service ❑ Routine Address Risk ❑ Retail ❑ Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone / �y _ -7_,9❑ Mobile Date: 3 Owner ' HACCP Y/N ElTemporary ElPre-operation P,w?!Z2&if ❑ Caterer ❑ Suspect Illness Person in Charge(PIC) Time ElBed& Breakfast E] General Complaint In: [_1HACCP sp Inector Out: Permit No. ElOther Each violation checked requires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. \ FOOD PROTECTION MANAGEMENT `kd ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties EMPLOYEE HEALTH ❑ 13. Handwash Facilities /" ❑ 2. Reporting of Diseases by Food Employee and PIC PROTECTION FROM CHEMICALS) ❑ 14.Approved Food or Color Additives ❑ 3. Personnel with Infections Restricted/Excluded ❑ 15.Toxic Chemicals FOOD FROM APPROVED SOURCE ❑ 4. Food and Water from Approved Source - Nor TIMEITEMPERATURE CONTROLS(Potentially Hazardous Foods) ❑ 5. Receiving/Condition ❑ 16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION " ❑ 19. Hot and Cold Holding ,^ _ ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control [j 9. Food Contact Surfaces Cleaning and Sanitizing REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP), El 10. Proper Adequate Handwashing E]21. Food and Food Preparation for HSP ❑ 11. Good Hygienic Practices 'CONSUMER ADVISORY' ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk'Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below 23. Management and Personnel (FC-2)(590.003) by a Board of Health member or its agent constitutes an 24. Food and Food Protection (FC-3)(590.004) order of the Board of Health. Failure to correct violations 25. Equipment and Utensils (FC-4)(590.005) cited in this report may.result in suspension or revocation of 26. Water, Plumbing and Waste (FC-s>(sso.00s) the food establishment permit and cessation of food establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address PF129. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S'S90lnspecfFormG14.0oc Inspector's Signature: Print: a ! PIC's Signature: Print: n 1 Page of c2Pages Violations Related to Foodborne Illness - K Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT _ S Grass-coatamnation I 590.003(A) Assignment of Responsibility" 3-302.11(A)(l) Raw Animal Foods Separated from 590.003(B) Demonstration of Knowledge`_ Cooked and RTE Foods* 2 103.11Person in charge--duties �� Contamination from Raw Ingredients 3-302.11(A)(2) Rain Animal Foods Separated fromEach EMPLOYEE HEALTH Other' 2 590.003(C) 1 Responsibility of the person in charge to Contamination from the Environment require reporting by food employees and 3-302.1I(A) Food Protection" applicants" 3-302.15 Washaw Fruits and Vegetables 590.003(F) Responsibility Of A Food Employee Or An 3-304.11 Food Contact with Equipment and Applicancro Report To The Person In Utensils* Charge' Contamination from the Consumer 590.003(G) Re orting by Person in Charee* 3-306.14(A)(B) Returned Food and Resetvice of Fual* 3 590.003(D) Exclusions and Restrictions' Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions Food 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food' q Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) G)m tlianee with Food Law'K 4-501.111 Manuul Wm ewashing-Hot Water 3-201.12 Food in,)Hermetically Sealed Container* Sanitization'Tetu)eratures"` 3-201.13 Fluid Milk and Milk Products* 4-501.1 L Mechanical Warewaslunn Hot Water 3-202.1.3 Shell Eggs* Sanitization Tent eratures* 3-202.14 Eg=sand Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made Front Potable Drinking Water" concentration and hardness, * 5-1.01.1.1 .Drinkin Water from an A moved S stem"` 4-601.11(A) Equipment Food Contact Sutlaees and Utensils C1eary� 590.006(A) Bottled Bets Drinking Water* 4-602.11 CleaningFrequencyof'EquipmentFood- 5)0.0(lfi(B) Water Meets Stand ods in ppr CMR 22.0` Contact Surfaces and Utensils Shettiish and Fish From an Approved Source 4-702.11 Frequency of Sanitization of Utensils and 3-201.14 Fish and Recreationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish" 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical" Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arens* Re ulafo Authorit 3-202.18 Shellaock.Identifieation Present" 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to WaSIO 3-201.17 Came Animals* 11 Good Hygienic Practices $ Receiving/Condition 2-401.11 Eating,Drinkijj or bacco" 3-202.11 PRFs Received at Proper Temperatures 2401.12 Discharges,From the Eyes, Nose and 3-202.15 Package Integrity- Mouth* 3-101.11 Food Safe and Unadulterated"* 3-301.12 Preventine Contamination When Tasting" (i TagsfRecords:Shelistoek I2 Prevention of Contamination from Hands 3-202.18 Shelistock Identification* 590.004(E) Preventing Contamination from 3-203.12 ShellstockIdentification Maintained* Employees' Tags/Records:Fish Products 13 Handwash Facilities Conveniently Located and Accessible 3-402.11 Parasite Destruction* 3-402.12 Records.Creation and Retention'` 5-21)3.11 Nmnbers and Ca aeities 590.004(1) Labeling of ingredients" 5-204.11 Lrx:ation and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibility.O aeration and yfaintenance /HACCP Pians Supplied with Soap and Nand Drying 3-502.11 S,ecialized Prose-asin>y Methods* Devices 3-502.12 Reduced oxygen pucka ring.criteria's 6-301.11 Handwashing Cleanser, Availabilit 8-103.12 Conformance with Approved procedures„ 6-301.12 Hand Drying Provision Denote"critical item in the izderal 1999 Foal Code or 103 CNIR 590.006. CITY OF SALEM BOARD OF HEALTH Establishment Name: T20/✓K w 7Jtrrt 1S / zS 2tZ/�X/Sf/ Date: /-4F-, Page: °Z Of r Item Code C-Critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red Item - Verified PLEASE PRINT CLEARLY fF O/h/i /e A/S1J ,4iC ,/ems( 2 r J D dwL C G'G/P f// C A-1 '.a '1 ' i I 11/Gr4d X,A, qw Ll yi lit f i Discussion With Person in Charge: Corrective Action Required: ❑ No ❑ Yes f I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next ins ection, to observe all conditions as described, and to Exclusion p ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension/revocation of ❑ Embargo ❑ Emergency Closure " your food permit. ❑ Voluntary Disposal ❑ -Other: E 3-501.14(0) PHFs Received at Temperaturzs� Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(items 1-22) (Cont.) 41.°F145°F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Cootie 'Mathods for Pi F; 14 Food or Color Additives 19 PHF Hot and Cold Holding 3-501.16(11) Codd PIIFR Maintained at or below 3-20112 hdobtivesk S90,004(F) 41°145°F* 3-302.14 Protection(romlhtapptoved .Addy ivcs' - IS Poisonous or Toxic Substances - 3-501.16(A) Hot PRFs Maintained at or above 7-101.1 1 Identifying Information-Original 1400F. Containers* 3-50Ll6(A) Roasts Held at or above 1.30°F. 7-102.11 Commat Name-Working Containers 20 Time as a Public Health Control 7-01.11 Separation-Stoi ace„ 3-501.19 Time as a Public Health Control* 7-202.11 Restriction-Presence andllse'" 590.004(H) VarianceRecuirement 7-202.12 Conditions of Use" 7-203-11 9'oxic Containers-Prohibhions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS(HSP) 7-204.12 Chennieals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Poe-packaged Juices and 7-204.14 Drying Agent,.Grneria* Bever mes with Warning I..abels* 3-80 L I I(B) Use of Pasteurized EL2ggs* 7-245.11 Incidental Food Contact,Lubricants* 3-81)1.1l(D) caw or Partially CtwAnima Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served * 7-206.1.2 Rodent Bait Stations* 3-801.11(C) Unopened Food Package Not Re,-served. 7-206.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY TIMElTEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of Animal Foods That are Raw. Undercooked or 16 Proper Cooking Temperatures for Not Otherwise Processed to Eliminate _PRFs e.r om-°r izoa i 3-401.11A(1)(2) Eggs 155'F 15 Sem Pathogens. : E s Immediate Service 145F15sec* 3-302.13 Pasteurized Togs Substitute for Raw Shell 3-401-11(A)(2) Comminuted Fish.,Meats&Game Eggs', Animals- 155'F 15 sec. * 3-401.11(B)(q(2) Pork and Beef Roast- 130'F121min* SPECIAL REQUIREMENTS 3-401.71(A)('2) Ramtes, htjected Meats-151 F 15 590.009(A)-(D) Violations of Section.590.009(A)-(D)in see * catering, mobile focal, temporary and 3-401.11(A)(3) Poultry.Wild Game. Smtfed PHFs, residential kitchen operations should be Stuftinle Containing Fish,Meat, r .: 'oii::d Cade)'the approP.'J ac Poultry or Ratites-1(,5"F 15.see. * above if related to foodborne illness 3-401 A I(C)(3) Whole-muscle,Intact BeefSteaks interventions and risk factors. Cather 145"F* 590.009 violations relating to good retail 3-401.12 Raw Anima Foods Crooked in a practices should be debited under#29- Microwave 165'F* Special Requirements. 3-401.11(A)(1)(b) All Other PRFs-- 145'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) PIIFs 165-F 15 sec. * (Items 23-30) 3-403.1.1(B) Microwave-165"F 2 Minute Standing Critical and non-cmical violations, which do not relate to the Time* foodborne illness interventiarts and risk factors Listed above, can be 3-403.1.1(0) Commercially Processed RTE Food- found in the following sections 2f the Food Code and 105 CMR 140'F* 590.000. 3-403.11(E) Remaining Unsliced Portions of Beef Item 1 Good Retail PracticesI FC 590A-00J Roasts* 23. - , Management and Personnel i FC- 2 .003 18 Proper Cooling of PRFs 24. Food and Food Protection FC-3 .004 j -- 3-501AZI A Cool itu,Cooked PHFs from 140 F to __ - '006 _i 25. 1 Equipment and Utensils __FC-4 5 ( ) a ° 26. Water,Plumbin and Waste FC 5 70'F Within 2 Hours and From 70'F 27. Ph sical FacilityFC__6 .007 to 41 1-145"F Within 4 Hours. * 28-A Poisonous or Toxic Materials FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambient _29Special Requirements .00.9 Temperature in„t edients to 41'F145"F 30 Other_ Within 4 Hours* Denote,orilical item in the federal 1999 Food Code or 10J CMR 590.004 . o�aaoa° ®©aQDVO FRANCHISE OWNER DREW'S DONUTS 152 Washington Street Salem, MA 01970 . (508)744-9888 Dunkin' Donuts and Baskin Robbins Menu For 282 Derby Street Donuts Coffee Bagels Tea Muffins Hot chocolate Cookies Coolatta Croissants Soda Sandwiches: Juice Egg & cheese Water Egg, cheese and sausage Egg, cheese and bacon Egg, cheese and ham Ham and cheese Chicken salad Cream cheese Danish Ice cream Condiments An independently owned and operated FRANCHISEE of the DUNKIN' DONUTS SYSTEM Massachusetts Department of Public Health Salem;Board of Health 120 Washington Street,0 Floor Division of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax(978) 745-0343 Namej� Dat T e of O eration s Tvoe otlnsoaction Ll. ILLI, I I 1Q Food Service �❑p-lRoutine Address Is RRetail Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone !� '7 „ ❑ Mobile Date: ❑ Temporary ❑ Pro-operation Owner f- HACCP Y/N ❑ Caterer ❑Suspect Illness Person ill Charge(PIC) ^ Time ❑ Bed&Breakfast El General Complaint Inspector / In://. El HACCP h i Outs-4 Permit No. ❑Other Each violation checked requires an explanation on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) ❑ 590.009(F) ❑ action as determined by the Board of Health. ---_ -- FOOD PROTECTION MANAGEMENT - ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties ElEHEALTH.. , -� 13. Handwash Facilites [.MPLOYEE_ PROTECTION FROM CHEMICALS ❑ 2. Reporting of Diseases by Food Employee and PIC -� - El3. Personnel with Infections Restricted/Excluded ❑ 14.Approved Food or Color Additives - El 15.Toxic Chemicals LFOOD.FROMAPPROVEDSOUR-CE.„_,_ 0 4. Food and Water from Approved Source 71MEITEMPERATURE CONTROLS(Potentially Hazardous.Foods) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling (r1-��RRO-TECTION FROM CONTAMINATION ❑ 19. Hot and Cold Holding„. h- ❑ 8. Separation/Segregation/Protection ❑ 20.Time As a Public Health Control El 9. Food Contact Surfaces Cleaning and Sanitizing �REOUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS(HSP)., ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing _ ❑ 11.Good Hygienic Practices CONSUMER ADVISORY . - , ❑22 Posting of Consumer Advisories I Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C) violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report, when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2) order of the Board of Health. Failure to correct violations 24. Food and Food Protection (FC-s)(590.0 so.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food 26. Water,Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION: S.5901nspecfF0m 14.tl Inspector's Signature: ( Print: PIC's Signature: Print: Q Page of ages ��1 1 Violations Related to Foodborne Illness Interventions and Risk Factors(Items 1-22) PROTECTION FROM CONTAMINATION 8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.11(A)(1) Raw Animal Foods Separated from 1 590.003(A) Assignment of'Responsibility* Cooked and RTE Foods* 590.003(B) Demonstration of Knowledge* Contamination from Raw ingredients 2-103.11 Person in charge-duties 3-302.11(A)(2) Raw Animal Foods Separated from Each Other* EMPLOYEE HEALTH Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 WashingFruits and Vegetables - applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An Utensils* Applicant To Report To The Person In Contamination from the Consumer Charge* 3-300.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting b Person in Char>e* I Food 3 590.003(D) Exclusions and Restrictions* - Disposition of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restrictions 3-701.'1'1 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE bnUd* 4 Food and Water From Regulated Sources ET Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501.111 Manual Warewashing-Hot Water - 3-201.12 Food in a Hermetically Sealed Container* Sanitization Te eratures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13Shell Eggs* Sanitization Tem erntures* 3-202.14 Eggs and Milk Products.Pasteurized* 4-501.114 Chemical Sanitization-temp.,pH, 3-202.16 Ice Made From Potable Drinking Water* concentration and hardness. * 5-101..11 DrinkingWater from an Approved S stent.* 4-601.11(A) Equipment Food Contact Surfaccs.and- 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(.B) Water Meets Standards in 310 CMR 22.0* 4-602.1.1 Cleaning Frequency of Equipment Food- Contact Surfaces and Utensils" an _ Food- Shellfish and Fish Froman Approved Source 4-701 11 Frequency of Sanitization of Utensils and - 3-201.14 Fish d Recreationally Caught Molluscan Food Contact Surfaces of E ui ment* Shellfish* 4-703.11 Methods of Sanitization-Hot Water and 3-201.15 Molluscan Shellfish from NSSP Listed Chemical* Sources* Al0 Proper,Adequate Handwashing Re u/afouthothorft - Game and Wild Approved by 2-301.11 Clean Condition-Hands and Arms* 3-202.18 Shellstock Identification Present* 2-301.12 Cleanina Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash'* - 3-201.17 Game Animals* I.1 Good Hygienic Practices 5 Receiving/Condition 2-40L11. Eating,Drinkinor Using Tobacco* 3-202.11 PHFs Received at Proper Tent ramres*. 2-401.12 ,Discharges From the Eyes,Nose and. 3-202.1.5 .Package Integrity, Mouth* 3-701.11 Food Safe and Unadulterated* 3-301.12 Preventin Contamination When Tasting,; 6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands 3-202:18 Shellstock Identification''` 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Employers* TagsfRecords: Fish Products 13 Handwash Facilities 3402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records.Creation and Retention* 5-203.11 Numbers and Capacities* 590.004(1) Labeling of Ingredients' 5-204.11 Location and Placement* � Conformance with Approved Procedures 5-205.11 Accessibility, Operation and Maintenance /HACCP Plans - Supplied with Soap and Hand Drying . Devices 3-502.1Specialized zsd Processing Methods* 6-301.11 Handwaehin Cleanser,Availability 3-502.122 Reduced oxygen packaging,criteria* 8-103.12 Conformance with Approved Procedures* 6-301.12 Hand D Provision *Denotes critical item in the fedend 1999 Food Cate or 103 Cb1R 590.000. - CITY OF SALEM BOARD OF HEALTH Establishment Name: 1141'K w� - Date: i, r Page:--"-1 of Item Code C-Critical Rem DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date No. Reference R-Red nem Verified PLEASE PRINT CLEARL 5 G o11c s c '7 n� s r,n i *A 3i. 1 Discussion With Person in Charge: Corrective Action Required: ❑ No es I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion ❑ Re-inspection Scheduled ❑ Emergency Suspension comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or suspension revocation of ❑ Embargo ❑ Emergency Closure your food permit. Y 13 Voluntary Disposal ❑ Other: 3-501.14(C) PHFs Received at Temperatures Violations Related to Foodborne 11Ines&interventions and Risk According to law Cooled to Factors(items 1-22) {Cont.} 41°F/450F Within 4 Hours. PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs 14 Food or Color Additives Fig- - PHF Hoz and Cold Holding 3-501.16($) Cold PHFs Maintained at or below 3-202,12 Additives* 590 004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives* 3-501.16(A) Hot PHFs Maintained of or above 15 Poisonous or Toxic Substances 140 * 7-101,11 Identifying Information-Original 3-501.16(A) Roasm Held at or above 130°F. Containers* 20 Time as a Public Health Control 7-102A I. Common Name-WorkingContainers* 3_501.19 Time as a Public Health Control" 7-202.11 ,R 7201.11 Separation-Storage estrictive-Ptesenceand-Use" 590.004H) Variance Requi 7-202.12 Conditions of Use" 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS HSP 7-204.11 Chemicals Criteria i Chemicals* 21 3-801.11(.A) Unpasteurized Pre-packaged Juices and 7-204.12 Chemicals for Washing Produce,Cdteris* Beverages with Wanuna labels* 7-204.14 encs,Criteria* 3-801.11($} Use of Pasteurized E * 7-205.11 Inadedental Foo Contact,Lubricants* 3-801.11(D) Raw or PartiallCooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served- 7- 1-06.12Rodent Bait Stations* Tracking Powders,Pest Control and 3-801.11(C) Unopened Food Packs Not Re-served. Monitoring* CONSUMER ADVISORY TIMEITEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or _ PHFs Not Otherwise Processed to Eliminate PathU ens.* 3-401.11A(l)(2) Eggs- 155°F 15 Sea ERee:ve Vr,✓(q]I Eggs-Immediate Service 145°Fl5.sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 31101.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. * 3-401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in catering,mobile food,temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165017 15 sec. * above if related to foodborne illness 3-401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145OF* 590.009 violations relating to good retail 3401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401:11(A)(1)(6) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403.11(A)&(D) PHFs 165°F 15 sec. * (Items 23-30) 3.403.11($) Microwave- 165`F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, cart be 3.403.11(C) Commercially Processed RTE Foal- found in thefollowing sections of the Food Code and 105 CMR 140°F* 590.000, 3-403.11($) Remaining Unsliced Portions of Beef Item. I Good Retail Practices .FC 590.000 Roasts* { 23. . Management and Personnel FC-2 _003 .I 18 Proper Cooling of PHFs 24. Food and Food Protection 1 FC-3 .004 3-501.14(A) Cootie Cooked PHFs from 140°F to 25' Equipment and Utensils ! FC-4 .005 -tI Cooling 26. -Water.Plumbingand Waste FC-5 006 t 70'F Within 2 Hours and From 70°F 27. Physical Facility FC-6 .007 to 41017/450F Within 4 Hours.* 28. Poisonous or Toxic Materials ! FC-7 ,008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .003 Temperature Ingredients to 41°F/45°F 30. 1 Other Within 4 Homs* s:;w:r :Gzax "Denotes critical item in the federal 1999 Food Code or 105 CMR 590.(100. Massachusetts Department of Pub4ic Health - 'Salem Board of Wealth X120 Washington Street,4'" Floor DIVISIOn of Food and Drugs Salem, MA 01970-3523 FOOD ESTABLISHMENT INSPECTION REPORT Tel. (978) 741-1800 Fax (978) 745-0343 Name Dat' I T e of O erationLsj Lype of inspection Food Service Routine Addressa Risk Retail Re-inspection Level ❑ Residential Kitchen Previous Inspection Telephone [I Mobile Date: OwnerJ3 * HACCP Y/N ❑ Temporary ElPro-operation I Lc(/ ❑ Caterer ❑ Suspect Illness Person In Charge(PIC) Time ❑ Bed&Breakfast ❑General Complaint El Inspector Ou -u� Permit No. ❑ O herr-_ Each violation checked r quires an explanation on the narrative page(s) and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors Anti-Choking Tobacco Violations marked may pose an imminent health hazard and require immediate corrective 590.009(E) [1590.009(F) ❑ action as determined by the Board of Health. --- - FOOD PROTECTION MANAGEMENT - ❑ 12. Prevention of Contamination from Hands ❑ 1. PIC Assigned/Knowledgeable/Duties [EMPLOYEE HEALTH'' - ''"'-"�"""" ').� El 13. Handwash Facilities _.. _-. --s ....d..v....�,.�.�. � ,0,.e.,,....-..N - - PROTECTIOFROM CHEMICALS ` ❑ 2. Reporting of Diseases by Food Employee and PIC 17114.Approved Food or Color Additives El3. Personnel with Infections Restricted/Excluded ,},� t 15 Toxic Chemicals _FOOD FROM APPROVED SOURCE== - � -a.Y„m,.,.„, - ❑ 4. Food and Water from Approved Source TIClr r MPERATURE CONTROLS(Potentlally Hazardous Fooda) ❑ 5. Receiving/Condition ❑ 16.Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17. Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑ 18.Cooling PROTECTION FROM CONTAMINATION _ ❑ 19. Hot and Cold Holding ❑ 8. Separation/Segregation/Protection ❑20.Time As a Public Health Control --_ _.-HIGHLY ._ __.___ q Food Contact Surfaces Cleaning and Sanitizing REOUIREMENTS FOR HIGHLY_SUSCEPTIBLE_.EPOdPULATIONS(HSP), ❑21. Food and Food Preparation for HSP ❑ 10. Proper Adequate Handwashing ❑ 11. Good Hygienic Practices LCONSUMEit ADVISORY,_ _ ❑22 Posting of Consumer Advisories Violations Related to Good Retail Practices Number of Violated Provisions Related Critical (C)violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors(Items 1-22): of Health. Non-critical (N)violations.must be corrected Official Order for Correction: Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code. This report,when signed below C x by a Board of Health member or its agent constitutes an 23. Management and Personnel (FC-2)(590.003) order of the Board of Health. Failure to correct violations 4. Food and Food Protection (FC-3)(590.004) cited in this report may result in suspension or revocation of 25. Equipment and Utensils (FC-4)(590.005) the food establishment permit and cessation of food . Water, Plumbing and Waste (FC-5)(590.006) establishment operations. If aggrieved by this order, you 27. Physical Facility (FC-6)(590.007) have a right to a hearing. Your request must be in writing 28.Poisonous or Toxic Materials (FC-7)(590.008) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of this order. 30. Other DATE OF RE-INSPECTION:__� S:S9JI,wpectFwm6-14.�c 1' Inspector's Signature: Print: PIC's Signature: �. Print: YCG�„(O Page_ f ages t� Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION F-8 Cross-contamination FOOD PROTECTION MANAGEMENT 3-302.1.1(A)(1) Raw Animal Foods Separated tram '1 I 590.003(A) Assn rment of Res tonsibility* Caked and RTE Foods* 590.003(B) Demonstration of 1{r owledge"' Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302.1l(A)(2) Raw Animal Foals Separated from Each Other* EMPLOYEE HEALTH _ Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.1 1(A) Food Protection* require reporting by food.empioyees and 3-302.15 -,Washing Fruits and Vegetables applicants* 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An * Applicant To Report To The Person In Utensils Contamination from the Consumer Charge* - 3-306.14(A)(B) Returned Food and Reservice of Food* 590.003(G) Reporting by Person in Charge* 3 590.003(1)) Exclusions and Restrictions* Food cion of Adulterated or Contaminated 590.003(E) Removal of Exclusions and Restr et ons -1 lei 11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Ford* 4 Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) _Compliance with Food Law* 4-501..111 Manual Wazewashing-Hot Water - 3-201.12 Food in a Hermetically Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* -Sanitization Tem eratures* 3-202.14 Eggs and Milk Products,Pasteurized* 4-501.114 Chemical:Sanitization-temp.,pH, 3-202.16 ice Made From Potable Drinking Water* concentration and hardness. * 5-101A I Drinking Water from an Approved System*tem* 4-601,11(A) Equipment Food Contac.Surfaces and 590.006(A) Bottled Drinkin Water* Utensils Clean* 590.006(B) Water Meets Standards in 310 CMR 22.0* 4-60211 Cleaning Frequency of Equipment Contact Surfaces and Utensils* Fish 3-20and - Food- Shellfish a andnd Recreationally From an Approved Source 4-702 1 1 Frequency of Sanitization of Utensils and - 1,14 Fish ationally Caught Molluscan Food Contact Surfaces of Equipment* Shellfish* 4-703.11 Methods of Sanitization-Har Water and 3-20LI5 Molluscan Shell fish from NSSP Listed Chemical* Sources* 10 Proper,Adequate Handwashing Game and Wild Mushrooms Approved by 2-301.11 Clean Condition-Hands and Arms* Regulatory Authority 3-202.18 Sheilstoek.Identification Present* 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* 19 Good Hygienic Practices 5 ReceivinglCondition 2401_11 Eating,Drinking or Using Tobacco* 3-202.1.1 PHFs Received at Proper Temperatures* 2-401,12 Discharges From the Eyes,Nose and 3-202.15 Package Integrity' Mouth* 3-101.11._ Foal Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Tags/Records;Shellstock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification * 590.004(E) Preventing Contamination from 3-203.1.2 Shellstock Identification Maintained* Em to ees* Tags/Records: Fish Products 13 Handwash Facilities 3-402.11 Parasite Destruction* Conveniently Located and Accessible 3-402.12 Records,Creation and RetentionA` 5.203.11 Numbers and Capacities* 590.004(1) Labeling of Ingredients* 5-204.11 Location and Placement* - 1 Conformance with Approved Procedures 5-"05.11 Accessibility,Operation and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11 Specialized Processing Methods* Devices 3-502.12 Reduced ox gen packaging,criteria* 6-301.11 Handwashmg Cleanser, Availability 8-103.12 Confotmance with A wdedl'rocedures* 6-301.1.2 1 Hand Dr 'n Provision ' Denotes,critical item in the Weral 1999 Fond Cate or 10 CMR 590.000. CITY OF SALEM BOARD OF HEALTH Establishment Name: �u Date: Pager Of Item Code C-critical Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date- No. Reference R-Red Item Vermed _ PLEASE PRINT CLEARLY en r i7 o I d -\4- So \o r I J. - I Aw r 2 J Discussion With Person in Charge: S—_� Lps Corrective ton Req edc ❑ / Yes I have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and toRe-inspection Scheduled ❑ Emergency Suspension Exclusion comply with all mandates of the Mass/Federal Food Code. I understand that noncompliance may result in daily fines of twenty-five dollars or sus ension/revocatio f ❑ Embargo ❑ Emergency Closure your food permit. ❑ Voluntary Disposal ❑ Other: - I 3-50I,14(C) PHFs Received at Temperatures Violations Related to Foodborne Illness Interventions and Risk According to Law Cooled to Factors(Items 1-22) (Cont.) _ 41°F/45°F Within 4 Hours, PROTECTION FROM CHEMICALS 3-501.15 Coolie Methods for PHFs 14 _ Food or Color Additives 19 PHF Hot and Cold Holding 3-202.12 Additives* 3-501,16(B) Cold PHFs Maintained at or below -3-302_14 Protection from Unproved Additives* 590.004(F) 410/450 F* 15 Poisonous or Toxic Substances 3-501.16(A) Hot PRFs Maintained at or above 140°F.* 7-101.11 Identifying Information-Original 3-501.16(A) Roasts Held at or above 130°F. Containers* 7-102.11. Common Name-WorkingContainers* Time as a Public Health Control 7-201.11 Separation-Storage* 3-501-19 Time as a Public Health Control" 7-202.11 .Restriction-Presence and Use* 590.004(H) Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7.204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP * 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 7-204.1Chemicals for Washing!Produce.Criteria Beverages with WarningLabels* 7-204.144 in Agents.Criteria* 7-205.11 Incidental Food Contact,Lubricants* 3-801.11(B) Use of Pasteurized Eggs* 7-206.11 Restricted Use Pesticides,Criteria* 3-801.1.1(D) Raw or Partially Cooked Animal Food and Raw Seed S outs Not Served.* 7-206.12 Rodent Bait Stations* 3-801-II(C) Unopened Food Package Not Re-served. 7-206.13 Tracking Powders,Pest Control and Monitoring* CONSUMER ADVISORY TIMEMEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 146 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate 3-401.11A(1)(2) Eggs- 155°F 15 Sec. Pathogens.'El "'" Eggs-Immediate Service 1450F15sec* 3-302.13 Pasteurized Eggs Substitute for Raw Shell 3401.11(A)(2) Comminuted Fish.Meats&Game Eggs* Animals-155°F 15 sec. * 3401.11(B)(1)(2) Pork and Beef Roast-130°F 17.1 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.00WA)-(D) I Violations of Section 590.009(A)-(D)in sec. * catering, mobile food,temporary and 3401.11(A)(3) Poultry,Wild Game,Stuffed PRFs, residential kitchen operations should be Staffing Containing Fish,Meat, debited under the appropriate sections Poul or Ratites-165'F 15 sec. * above if related to foodborne illness 3-40L11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165`F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for tot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403.11(A)&(D) -PHFs 165°F 15 sec.* (Items 23-30) 3-403.11(B) Microwave- 165°F 2 Minute Standing Critical.and non-critical violations,which do not relate to the Time* foodborne illness interventions and riskfactors listed above,can be 3-403.11(C) Commercially Processed RTE Food- found in the follomfng sections of the Food Code and 105 CMR 140°F* 590.000. 3-403.11(E) - Remaining Unsliced Portions of Beef Item Good Retail Practices .FC $ 90.(!00 Roasts* 23. Man nt and Personnel FC-2 .003 .i 18 Proper Coaling of PHFs 24. _ Food and Food Protection FC-3 .004 1 25. Equipment and Utensils FC-4 005 1 3-501.14(A) Cooling Cooked PIFs from 140°F to 28. Water.Plumbinq and Waste FC-5 .006 70°F Within 2 Hours and From 707 - 27. Physical FacilityFC-6 .007 to 41°F/4.5°F Within 4 Hours. * 28. Poisonous or Toxic Materials FC--7 .008 3-501.14(B) Cooling PHFs Made From Ambient 29. Special Requirements .009 Temperature Ingredients to 41°F/45°F 1 30 1 Other _! _ Within 4 Hours* s:sumommer.-z ex Devours critical hem in the federal 1999 Foal Cade a 105 CMR 590.000. , CITY OF SALEM ^/ '� BOARD OF/HEALTH Establishment Name: t�� VA'l th>l� aX� Der za Date: Page: of _ Item Code C—CrnlCal Item DESCRIPTION OF VIOLATION/PLAN OF CORRECTION Date. No. Reference R—Red nem Verified PLEASE PRINT CLEARLY/ S ✓1//P a. �1 eDCs A,( tl c / le 5 u �0 G/I464r Discussion With Person in Charge: Corrective Action Required: ❑ No es have read this report, have had the opportunity to ask questions and agree to correct all ❑ Voluntary Compliance ❑ Employee Restriction/ violations before the next inspection, to observe all conditions as described, and to Exclusion Fcomply with all mandates of the Mass/Federal Food Code. I understand that Re-inspection Scheduled Ll Emergency suspension noncompliance may result in daily fines of twenty-five dollars or 5 spension/revocation of ❑ Embargo ❑ Emergency Closure your food permit. ///J ❑ Voluntary Disposal ❑ Other: U art 3-501.14(0) PHFs Received at Temperatures Violations Related to Foodborne Illness.Interventions and Risk According to Law Cooled to Factors(Items 1.22) (Cont.) 41'F/45'F Within 4 Hours. PROTECTION FROM CHEMICALS _ 3-501.15 CoolingMethods for PHFs 14 . Food or Color Additives - 19 PHF Not and Cold Holding 3-501.16(B) Cold PHFs Maintained at or below 3-202,12 Additives* 590.004(F) 410/450 F* 3-302.14 Protection from Unapproved Additives' 3-501.16(A) Hot PHFs Maintained at or above 15 Poisonous or Toxic Substances 140"F 7-10111 Identifying Information-Original 3-501,16(A) Roasts Held at or above 130°F. Containers* 7-102.11, Common Name-Working Containers* 20 Time as a Public Health Control 7-201.11 Separation-Storage* 3-501.19 Time as a Public Health Control* 7-202.11 .Restriction-Presence and Use* 590.004(11} Variance Requirement 7-202.12 Conditions of Use* 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTS FOR HIGHLY SUSCEPTIBLE 7-204.11 Sanitizers.Criteria-Chemicals* POPULATIONS HSP 7-204.12 Chemicals for Washing Produce,Criteria* 21 3-801.11(A) Unpasteurized Pre-packaged Juices and 3-801.11(B) Use of Pasteurized E * .Bevena es with Warning labels* 7-204.14 h encs.Criteria* 7-205.11 incidental Food Contact,lubricants* 3-801.11(0) Raw or PartiallyCooked Animal Food and 7-206.11 Restricted Use Pesticides,Criteria* Raw Seed Sprouts Not Served.* 7-206.12 Rodent Bait Stations* 3-801.11(C) Unopened Pcwd Package Not Re-sery 7-206.]3 Tracking Powders,Pest Control and al. Monitoring* CONSUMER ADVISORY TIME(fEMPERATURE CONTROLS 22 3-603.11 Consumer Advisory Posted for Consumption of 16 Proper Cooking Temperatures for Animal Foods That are Raw.Undercooked or PHFs Not Otherwise Processed to Eliminate Path ens* Eggs-immediate Service 145°F15sec* EM1 ove i/V m+ 3 401.I1A(1)(2) Eggs- 1 IS Sea. 3-302.1 �s .3 Pasteurized E Substitute for Raw Shell 3.401.11(A)(2) Comminuted Fish.Meats&Game E Animals-155°F 15 sec. * 3.401.11(B)(1)(2) Pork and Beef Roast-130°F 121 min* SPECIAL REQUIREMENTS 3-401.11(A)(2) Ratites,Injected Meats-155°F 15 590.009(A)-(D) Violations of Section 590.009(A)-(D)in sec. * cratering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-165°F 15 sec. * above if related to foodborne illness 3401.11(C)(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F" 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited tinder#29- Microwave 165°F* Special Requirements. 3-40lAI(A)(1)(b) All Other PHFs- 145°F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3.403A I(A)&(D) PHFs 1657 15 sec.* (Items 23-30) 3.403.11(8) Microwave- 165`F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Food- found in the following sectionsof the Food Code and 105 CMR 140°F* 590.000, 3-403.11(E) Remaining Unsliced Portions of BeefItem�I Good Retail Practices I ,FC 590.000 Roasts" 1 23. , Management and Personnel (FC-2 18 Proper Cooking of PHFs 24. Food and Food Protection FC_3 -3 .004 25. Equipment and Utensils I FC-4 .005 I 3-501.14(A) Cooling Cooked PHFs from 140°F to 2i, Water.Plumbing and Waste I FC-5 .006 1 70°F Within 2 Hours and From 70°F 27. Physical Facili , FC-6 .007 to 41°F/45'F 1i nhin 4 Hours. * 28. Poisonous or Toxic Materials ! FC-7 .008 3-501.14(B) Cooling PHFs Made From Ambiens 29. Special Requirements 009 Temperature Ingredients to 41 017/450F 130. f Other I Within 4 Hours* s:svm .rze:� 'Denotes critical item in the federal 1999 Foci Code or 105 CMR 590.000. Massachusetts Department of Public Health Salem Board of Health 120 Washington Street,4s' Floor Division of Food and Drugs Salem, MA 01970-3523 Tel. (978)741-1800 Fax(978) 745-0343 City/Town Of ,:�(Ijannn Address: FOOD ESTABLISHMENT INSPECTION REPORT Tel. Nam Date Typ of Operatfon(s) Type of Inspection ` 1 � Service outine Address kQ Risk etail ❑ Reinspection Telephone Level El Residential Kitchen Previous Inspection El Date: Owner HACCP YM [1 Temporary ElPre-operation ❑ Caterer ❑Suspect Illness Person-in-Charge C) ) Ti e ❑ Bed 8 Breakfast ❑❑General HACCP Complaint I '-J�Z Inspector Out: Permit No. ❑.Other Each violation checked requires an explanr n on the narrative page(s)and a citation of specific provision(s)violated. Non-compliance with: Violations Related to Foodborne Illness Interventions and Risk Factors_(Red Items) Anti-Choking 590.009(E) ❑n'`. Vipose an imminent health hazard and re- immediate Tobacco 590.002(F) El marked may V y p require Allergen Awareness 590.002(G) ❑ corrective action as determined by the Board of Health. [RO-06, ROTECT]ON MANAGEMENT- _- El_, 12. Prevention of Contamination from Hands El 1. PIC Assigned/Knowledgeable/Duties ❑ 13. Handwash Facilities 'EMPLOYEE HEALTH -__�.-.i ❑ 2. Reporting of Diseases by Food Employee and PIC iPROTECT10NfROMCNEMICALS- E] 14.Approved Food or Color Additives E] 3. Personnel with Infections Restricted/Excluded _ E] 15.Toxic Chemicals LFOOD FROM APPROVED SOURCE___ 4. Food and Water from Approved Source TIMFITEMPERATURE:CONTROLS(P._otaMlalty Hazardous Foa]s)'-� ❑ 5. Receiving/Condition ❑16. Cooking Temperatures ❑ 6. Tags/Records/Accuracy of Ingredient Statements ❑ 17.Reheating ❑ 7. Conformance with Approved Procedures/HACCP Plans ❑18. Cooling _P O_TECTIONFROM CONTAMINATION ❑ 19. Hot and Cold Holding ❑ 8.Separation/Segregation/Protection ❑20. Time as a Public Health Control 9. Food Contact Surfaces Cleaning and Sanitizing !REQUIREMENTS FOR HIGHLYSUSCEPTIBLE=POPULATIONS(H.BP_)3 10. Proper Adequate Handwashing ❑21.Food and Food Preparation for HSP ❑ 11.Good Hygienic Practices CONSUMER`ADVISORY ❑22. Posting of Consumer Advisories Violations Related to Good Retail Practices-(Blue Number of Violated Provisions Related Items) Critical(C)Violations marked must be corrected To Foodborne Illnesses Interventions immediately or within 10 days as determined by the Board and Risk Factors (Red Items 1-22); of Health. Noncritical (N)violations must be corrected Official Order for Correction:Based on an inspection immediately or within 90 days as determined by the Board today, the items checked indicate violations of 105 CMR of Health. 590.000/federal Food Code.This report,when signed below C N by a Board of Health member or its agent constitutes an 23. Management and Personnel (Fc-2x 90.00 a) order of the Board of Health. Failure to correct violations �) 24. Food and Food Protection (FC•3x590.004) cited in this report may result in suspension or revocation of �/ 25. Equipment and Utensils (FC-4x590.005) the food establishment permit and cessation of food 26.Water, Plumbing and Waste (FCsx590.006) establishment operations. If aggrieved by this order,you 27. Physical Facility (FC-6x590.007) have a right to a hearing. Your request must be in writing 28. Poisonous or Toxic Materials (FC-7x590.006) and submitted to the Board of Health at the above address 29. Special Requirements (590.009) within 10 days of receipt of thi order. 30. Other DATE OF RE-INSPECTION. a o-ada l l � Inspector's Signature: Print: Lie a PICS Signature• Print: y' Q -1Page of Pages �iv� t Ua �I te_ w. a�3 e4 Lo6 S .+..�-Y.�.�-����-.�ti....^Y.•. ./1...,- `.-...,-I"-.+\�... _ •.r--.ten.-.:. -�.�"w...- , ..-.n...-. ,.1.•� .. � .-� r Violations Related to Foodborne Illness Interventions and Risk Factors(items 1-22) PROTECTION FROM CONTAMINATION FOOD PROTECTION MANAGEMENT 8 Cross-contamination _ 3-302.11(A)(l.} Raw Animal Foods Separated from 590 1 590.003(A) DemAsso meat of Responsibility* Cooked and RTE Foods* 2-103.11 Demonstration of Knowledge" Contamination from Raw Ingredients 2-103.11 Person in charge-duties 3-302.1.1(A)(2) Raw Animal Foods Separated from Each EMPLOYEE HEALTH Other* Contamination from the Environment 2 590.003(C) Responsibility of the person in charge to 3-302.11(A) Food Protection* require reporting by food employees and 3-302.15 Washing Fruits and Ve a etables o 3-304.11 Food Contact with Equipment and 590.003(F) Responsibility Of A Food Employee Or An - Applicant To Report To The Person In Utensils* Contamination from the Consumer Charge* 3-306.14(A)(S ,Returned Food and Reservice of Food" 590.003 G) Reporting b y Person in Charge* 3 590.003(D) Exclusions and Restrictions" DlSPOSMOn of Adulterated or Contaminated Food 590.003(F,) Removal of Exclusions and ResYn'ctions 3-701.11 Discarding or Reconditioning Unsafe FOOD FROM APPROVED SOURCE Food* a Food and Water From Regulated Sources 9 Food Contact Surfaces 590.004(A-B) Compliance with Food Law* 4-501-171 Manual Warewashing-Hot Water 3-201.12 Food in a Hermetical Sealed Container* Sanitization Temperatures* 3-201.13 Fluid Milk and Milk Products* 4-501.112 Mechanical Warewashing-Hot Water 3-202.13 Shell Eggs* _ Stinitization Tem eramres* 3.202.14 E«<=s and Milk Products,Pastenriud* 4-501.114 Chemical Sanitization-temp.,pH; 3-202.1.6 Ice Made From Potable Drinking Water* concentration and hardness, 5-101.11 Drinking Water,from an Approved System* 4-601A I(A) Equipment Food Contact Surfaces and 590.006(A) Bottled Drinking Water* Utensils Clean* 590.006(B) Water Meets Stand rd in 310 CIvIR,222.0* 4-602.11 Cleaning Frequency of Equipment Fond Shellfish and Fish From an Approved Source Contact Surfaces and Utensils* 4- 3-201.14 Fish and Recreationally Caught Molluscan 702.11 Frequen y of Sanitization of Utensils and Food Contact Surfaces of Equipment* 3-20115 Mo Shellfish* 4-703.11 Methods ofSanitization-HotWaterand lluscan Shellfish from:"7SSF 31sta1 Chemical* Sources* Game and Wild Mushrooms Approved by 10 Proper,-Adequate Handwashing Re ulato Aufhonl 2-301..11 Clean Condition-Hands and Arms* 3-202.18 Shellstock identification Present' 2-301.12 Cleaning Procedure* 590.004(C) Wild Mushrooms* 2-301.14 When to Wash* 3-201.17 Game Animals* - 11 - Good Hygienic practices - 5 Receiving/Condition 2401.11 Eating,Drinking or Using Tobacco* 3-202.11 PRFs Received at Proper Temperatures* 2401.12 . Discharges:From the Eyes,Nose and 3-202.1.5 Package Integrity* Mem 3-101.1 I _Food Safe and Unadulterated* 3-301.12 Preventing Contamination When Tasting* 6 Togs/Rerords;Shelistock 12 Prevention of Contamination from Hands 3-202.18 Shellstock Identification* 590.004(E) Preventing Contamination from 3-203A2 She0stookldentifcatioYtM__ainzair!ad'kEmloees * .. - . Tags/Records:'Fish Products 13 Handwash Facilities 3402.11 Parasite Destrucror!y --- Convenientty Located and Accessible 3-402.12 Records,Creation and Retention* 5-203.11 Numbers and Ca acities*. 590.004(1) Labeling o1 Ingredients* 5-204.11 Location and Placement* 7 Conformance with Approved Procedures 5-205.11 Accessibilit , ration and Maintenance /HACCP Plans Supplied with Soap and Hand Drying 3-502.11S ecialized Processing Methods* Devices 3-502.1.2 Reduced oxygen packaging,criteria* -6-301.11 Handwashin Cleanser,.Availabilit 8-103.12I Conformance with Approved Procedures* 6-301..12 Hand Drying Provision °Denotes critical item in the Federal 1999 Foot Code or 1 US CMR 590.000, r • • MINN.M-1 ���� ',. .. ►.��: . �%..1�►- �;: _ :��+�i1'rl�it�•�. , ._, _ . : , I !-,1111 WON 4u - go,V i i [ - 3-SOL14(C) PHFs Received at Temperatures f Violations Related to Foodborne 111ness.Interventions and Risk According to Law Cooled to Factars(Items't-W) (Cont) 41'F145°F Within 4 Hours. CHEMICALS 3-501.15 CoolingMethods for PHFs PROTECTION FROM CHEMICALS14 Food or ICAColoAdditives 19 PHF Hot and Cold Holding 3-SOl.ifi(B} Cold PRFs Maintained at or below 3-202.12 Additives* 590.004(F) 41'145'F* R 3-302.14 Protection from Una roved Additives'° 3-501.16(A) - Hot PRFs Maintained at or above 15 Poisonous or Toxic Substances 140`F. * 7-10131 identifying Information-Original r Contttinets* � 3-501.16(A) Roasts Held at or soave 130'F. * 7-702.11. Common Name-Working Containers* 20 Time as a Public Health Control 7-301.12 S arad�-Stora " 1 3-501,19 � Time as a Public Health Central* 7-202.11 .Restriction-PresenceandUse* 590.004(H) Variance Re uisemem 7-202.12 Conditions of Use+ 7-203.11 Toxic Containers-Prohibitions* REQUIREMENTSNS(HSP) OR HIGHLY SUSCEPTIBLE POPUONS N 7-204.11 Sanidzers.Criteria-Chemicals* LATI 7-204.12 Chemicals for Washin Produce,Criteria* 27. 3-801.11(A) Unpasteurized Pre-packaged Iuices and 7-204.14 Drying Agents.Criteria* Bevemees with Wanton Labels* 7-205.11 Incidental Food Contact,Lubricants* 3-801AI(B) Use of Pasteurized Eggs* 7-206.11 -Restricted Use Pesticides,Criteria* 3-801.11(D) Raw or Partially Cooked Aniutal Food and Raw,Seed S ns Not Served. 7-206.i2 . -Rodent Bait Stations* 3-801.11(C) Unopened Food Parka T Not Re-served. 7-205.13 Tracking Powders, Pest Control and Monitoring* CONSUMER ADVISORY i OLS 22 3-603.11 Consumer Advisory Posted for Consumption of TiMEITEMPERATURE CONTROLS IS Proper C ONTRoldnq Temperatures for Animal Foods That are Raw,Undercooked or PHFs Not OdterwiseProce3sed to Eliminate I - P�o�'* rvs rn,�xr 3-401.11A(1)(2) EggSec.s- 155°F 15 E -Immediate Service 145'F15sec* 3-302.13. Pasteurized Eggs Substitute for Raw Shell E 3-401.11(A)(2) - Comminuted Fish.Meats&Game Animals-155'F 15 sec. 340111(13)(11(21 Port:and Beef Roast-130'F 121 min* SPECIAL REQUIREMENTS 3-401.11(,A)(2) Ratites, Injected Meats-155°F 15 590.009(A)-(D) Violations of Section.590.009(A)-(D)in see.* catering,mobile food, temporary and 3-401.11(A)(3) Poultry,Wild Game,Stuffed PHFs, residential kitchen operations should be Stuffing Containing Fish,Meat, debited under the appropriate sections Poultry or Ratites-I65'F 15 sec. * above if related to foodborne illness 3401.110(3) Whole-muscle,Intact Beef Steaks interventions and risk factors. Other 145°F* 590.009 violations relating to good retail 3-401.12 Raw Animal Foods Cooked in a practices should be debited under#29- Microwave 165°F* Special Requirements. 3-401.11(A)(1)(b) All Other PHFs- 135'F 15 sec. 17 Reheating for Hot Holding VIOLATIONS RELATED TO GOOD RETAIL PRACTICES 3-403;11(A)&(1)) P17[Fs 165°F 15 see. * (Items 23-30) 3403.11(B) Microwave-'165'F 2 Minute Standing Critical and non-critical violations,which do not relate to the Time* foodborne illness interventions and risk factors listed above, can be 3403.11(C) Commercially Processed RTE Foal- found in the following,sectionsof the Food Code and 105 CMR 140°F* 590.000. 34WAI(E) Remaining Unsliced Portions of Beef IOem { Good Retail Practices FC 590.000 Roasts* 23; 1 Management and Personnel FC-2 .003 118 Proper Cooling of PHFs i 24. i Food and Food Protection ( FC-3 .004 �25. Equipment and Utensils IFC-4 .005 I 3-50IA4(A) Cooling Cooked PHFs front 140°F to i 2, Water.Plumbin, and Waste i Fc-5 '006 70°F Within 2 Hours and From 70°F 27. P�hv ca Facility FC-6 .�7 to 41'F/45'F Within 4 Homs.* 1 28. Poisonous or Toxic Materials i FC 7 .008 ' 3-501.14(.B) Cooling PRFs Made From Ambient 29. S ectal R uirements .009 Temperature Ingredients to 41°F145°F 1 30, -- Within 4 Hours* Denotes aiticat hem in the federal 1999 Foal Cods:"103 C14iR 590.000. j